Sensing for heart failure management

ABSTRACT

In some examples, determining a heart failure status includes using an implantable medical device configured for subcutaneous implantation and comprising a plurality of electrodes and an optical sensor. Processing circuitry of a system comprising the device may determine, for a patient, a current tissue oxygen saturation value based on a signal received from the at least one optical sensor, a current tissue impedance value based on a subcutaneous tissue impedance signal received from the electrodes, and a current pulse transit time value based on a cardiac electrogram signal received from the electrodes and at least one of the signal received from the optical sensor and the subcutaneous tissue impedance signal. The processing circuitry may further compare the current tissue oxygen saturation value, current tissue impedance value, and current pulse transit time value to corresponding baseline values, and determine the heart failure status of the patient based on the comparison.

TECHNICAL FIELD

The disclosure relates generally to medical device systems and, moreparticularly, medical device systems configured to monitor patientparameters.

BACKGROUND

Some types of implantable medical devices (IMDs) may be used to monitorone or more physiological parameters of a patient, such as physiologicalparameters associated with cardiac function. Such IMDs may include, ormay be part of a system that includes, sensors that detect signalsassociated with such physiological parameters; e.g., cardiacdepolarization or tissue impedance. Values determined based on suchsignals may be used to assist in detecting changes in cardiac conditionssuch as heart failure, in evaluating the efficacy of a therapy, or ingenerally evaluating cardiac health.

Implantable devices that monitor physiological parameters related to aheart failure condition of a patient may evaluate values associated withthe physiological parameters, such as to determine whether the valuessatisfy a threshold or have changed. Values that satisfy a threshold orthat have changed may indicate that a therapy being administered to thepatient is not effectively managing the patient's heart failurecondition.

SUMMARY

In general, this disclosure is directed to techniques for determining aheart failure status of a patient. Such techniques may includeperforming assessments associated with aspects of a patient's cardiacfunction, and determining a hemodynamic profile of the patient based onthe outcome of the assessments. Such hemodynamic profiles may indicate aheart failure status of the patient, e.g., whether the patient's heartfailure status is stable or progressing, and may help guide therapyselection.

When a patient presents at a healthcare facility with acute heartfailure symptoms, a clinician may perform assessments associated withaspects of the patient's cardiac function, such as preload, afterload,and perfusion, by observing surrogate parameters. For example, in orderto assess preload (a measure of heart filling capacity), a clinician mayobserve the patient for signs of congestion, such as peripheral edema,jugular venous dilatation, ascites, or others. To assess afterload (ameasure of vascular resistance) a clinician may use blood pressuremeasurements as a surrogate parameter to determine whether the patient'svascular resistance is high and therefore indicative ofvasoconstriction. To assess perfusion (an indication of supply orcardiac output versus metabolic demand or body surface area) a clinicianmay observe the patient for signs of inadequate peripheral perfusion,such as cold sweated extremities, oliguria, mental confusion, dizziness,and numbness and tingling in extremities. Based on the combined outcomeof these assessments, a clinician may identify a hemodynamic profile ofthe patient (e.g., congested+vasoconstricted+adequately perfused), andprescribe treatment in accordance with the hemodynamic profile. Suchtreatment may include drug therapy to compensate for a loss of cardiacfunction caused by the patient's heart failure condition. Thereafter,the patient may be discharged from the healthcare facility withinstructions for continuing the prescribed therapy and schedulingregular clinician visits.

For one or more reasons, however, a patient's heart failure condition,which may be in a state of chronic but stable decompensation whenadequately managed by therapy, may become unstable and acutelydecompensate, that is, no longer adequately be managed by therapy,between clinician visits. For example, the progressive nature of heartdisease may cause a patient not exhibiting congestion at a previousclinician visit to become congested between visits, which may be due tophysiological cardiac remodeling that occurs in the progression of HF.Or, a confounding factor such as over-the-counter medication intake maybe eliminated or introduced, leading to a change in vasoconstriction. Inany such cases, the patient may become symptomatic and acutelydecompensate between visits. In some examples, such acute decompensationmay lead to hospitalization or other adverse medical events.Consequently, clinical outcomes for heart-failure patients would benefitfrom methods for updating a patient's hemodynamic profile and heartfailure status between clinician visits, which in turn may enableprediction of a likelihood that an acute decompensation andhospitalization may occur. In response to such a prediction, a patient'streatment may be adjusted (e.g., by modifying a drug regimen), which mayhelp reduce the patient's likelihood of acute decompensation andhospitalization.

However, assessment of a patient's heart failure status based onobservations of the surrogate parameters of congestion (i.e.,hypervolemia), peripheral perfusion, and vascular resistance may belimited to clinical or hospital settings. For example, such assessmentsmay require medical expertise unavailable to the patient in anon-clinical environment. Thus, methods for updating a patient'shemodynamic profile between clinician visits may be performed using oneor more medical devices, such as the subcutaneously-implantable medicaldevices described herein.

Accordingly, techniques described herein may include automaticallydetecting and monitoring parameters associated with cardiac functionthat are measurable by one or more medical devices, which may include asubcutaneously implantable medical device, which may in some cases beleadless. As with a clinician's assessments, such parameters may beindicative of congestion, peripheral perfusion, and vascular resistanceor blood pressure. When taken together, this three-part evaluation of apatient's cardiac function may provide a robust indication of whether aheart failure status of the patient has changed, which may be useful indetecting, or assessing the patient's likelihood of, acutedecompensation and in proactively modifying the patient's therapy.Because the methods described herein are intended to be performed by oneor more medical devices in between clinician visits, such methods mayuse sensors, such as electrodes and optical sensors, to monitor certainparameters of the patient's cardiac function in place of the signsobserved by a clinician.

For example, instead of assessing external signs of congestion, some ofthe methods described herein include determining a subcutaneous tissueimpedance value (Z), which is a surrogate for congestion. Instead ofassessing signs of peripheral perfusion, some of the methods describedherein include determining a tissue oxygen saturation (StO₂) value,which provides a surrogate for cardiac output and peripheral perfusion.Instead of assessing vascular resistance via blood pressuremeasurements, some of the methods described herein include determining apulse transit time (PTT) value. It should be noted that, although notstrictly equivalent, vascular resistance and blood pressure may bedescribed interchangeably as being assessable by PTT. In some examples,PTT may be used to determine a measurement of pulse wave velocity (PWV),the former of which indicates the time it takes a pulse wave (e.g., ofan ECG signal) to travel over an estimable distance within the patient.In such examples, the estimable distance traveled by the pulse wave maybe divided by a determined PTT value to arrive at a PWV value. The PWVvalue may be used instead of or in addition to the PTT value inassessing vascular resistance but, for a given patient, the estimabledistance can be assumed constant, and changes in PTT consideredrepresentative of changes in PWV. For the sake of clarity, thetechniques described herein are described as assessing vascularresistance based on PTT.

A comparison of current values of Z, StO₂, or PTT to correspondingbaseline values may be used to determine a status of the patient's heartfailure condition, such as whether the condition is stable or haschanged, e.g., progressed or worsened. In techniques described herein, aone or more IMDs may determine a patient's heart failure status andtransmit the heart failure status to a remote computer or other deviceexternal to the patient. In some cases, the patient's heart failurestatus may indicate whether the patient is congested, inadequatelyperfused, or vasoconstricted, and may further indicate the patient'slikelihood of decompensation or hospitalization. The remote computerthen may transmit instructions for a medical intervention (e.g.,instructions for changes to a drug regimen), to a user device used bythe patient or a caregiver. In this manner, a patient's heart failuretreatment may be modified as needed in between clinic visits, which mayhelp avoid adverse medical events such as recurrent symptoms orhospitalization.

In examples in which a clinician is involved in determining theinstructions for the medical intervention, the techniques describedherein may enable the clinician to make determinations regarding themedical intervention by accounting for the interrelated nature of thephysiological causes of the patient's Z, StO₂, or PTT values. Forexample, a downward trend in a Z value may indicate that the patient'slikelihood of congestion has increased, but the clinician may behesitant to modify the patient's drug regimen on this basis alone.However, by additionally providing StO₂ and PTT values, the techniquesdescribed herein may enable the clinician to determine whether aparticular modification to the patient's drug regimen to addresspotential congestion (e.g., increasing a dosage of a diuretic drug) maybe desirable. In this manner, the techniques described herein mayincrease the clinician's confidence in prescribing a particular medicalintervention, which may lead to improved clinical outcomes for thepatient.

In one example, a method for determining a heart failure status of apatient using an implantable medical device configured for subcutaneousimplantation outside of a thorax of the patient, the implantable medicaldevice comprising a plurality of electrodes and at least one opticalsensor, comprises, by processing circuitry of a medical device systemcomprising the implantable medical device: determining a current tissueoxygen saturation value of the patient based on a signal received fromthe at least one optical sensor; determining a current tissue impedancevalue of the patient based on a subcutaneous tissue impedance signalreceived from a first at least two of the plurality of electrodes;determining a current pulse transit time value of the patient based on acardiac electrogram signal received from a second at least two of theplurality of electrodes and at least one of the signal received from theat least one optical sensor and the subcutaneous tissue impedancesignal; comparing the current tissue oxygen saturation value, thecurrent tissue impedance value, and the current pulse transit time valueto corresponding ones of a baseline tissue oxygenation saturation value,a baseline tissue impedance, and a baseline pulse transit time value;and determining the heart failure status of the patient based on thecomparison.

In another example, a system for determining a heart failure status of apatient using an implantable medical device configured for subcutaneousimplantation outside of a thorax of the patient comprises theimplantable medical device, which comprises at least one optical sensor;and a plurality of electrodes; and processing circuitry configured to:determine a current tissue oxygen saturation value of the patient basedon a signal received from the at least one optical sensor; determine acurrent tissue impedance value of the patient based on a subcutaneoustissue impedance signal received from a first at least two of theplurality of electrodes; determine a current pulse transit time value ofthe patient based on a cardiac electrogram signal received from a secondat least two of the plurality of electrodes and at least one of thesignal received from the at least one optical sensor and thesubcutaneous tissue impedance signal; compare the current tissue oxygensaturation value, the current tissue impedance value, and the currentpulse transit time value to corresponding ones of a baseline tissueoxygenation saturation value, a baseline tissue impedance, and abaseline pulse transit time value; and determine the heart failurestatus of the patient based on the comparison.

In another example, a system for determining a heart failure status of apatient using an implantable medical device configured for subcutaneousimplantation outside of a thorax of the patient comprises theimplantable medical device, which comprises: at least one opticalsensor; a plurality of electrodes; and processing circuitry configuredto: determine a current tissue oxygen saturation value of the patientbased on the signal received from the at least one optical sensor;determine a current tissue impedance value of the patient based on asubcutaneous tissue impedance signal received from a first at least twoof the plurality of electrodes; determine a current pulse transit timevalue of the patient based on a cardiac electrogram signal received froma second at least two of the plurality of electrodes and at least one ofthe signal received from the at least one optical sensor and thesubcutaneous tissue impedance signal; determine whether a differencebetween the current tissue oxygen saturation value and the baselinetissue oxygen saturation value satisfies a tissue oxygen saturationthreshold value that is associated with a change in a tissue-perfusionstatus of the patient; determine whether a difference between thecurrent tissue impedance value and the baseline tissue impedance valuesatisfies a tissue impedance threshold value that is associated with achange in a congestion status of the patient; determine whether adifference between the current pulse transit time value and the baselinepulse transit time value satisfies a threshold pulse transit time valuethat is associated with a change in a blood-pressure status of thepatient; determine the heart failure status of the patient based on atleast one of the difference between the current tissue oxygen saturationvalue and the baseline tissue oxygen saturation value, the differencebetween the current tissue impedance value and the baseline tissueimpedance value, and the difference between the current pulse transittime and the baseline pulse transit time; and transmit the heart failurestatus of the patient to a remote computer; and the remote computer,wherein the remote computer comprises processing circuitry configuredto: receive the heart failure status of the patient transmitted by theprocessing circuitry of the implantable medical device; and transmit theinstructions for the medical intervention to a user device.

In another example, a system for determining a heart failure status of apatient comprises means for determining a current tissue oxygensaturation value of the patient based on a signal received from at leastone optical sensor; means for determining a current tissue impedancevalue of the patient based on a subcutaneous tissue impedance signalreceived from a first at least two of a plurality of electrodes; meansfor determining a current pulse transit time value of the patient basedon a cardiac electrogram signal received from a second at least two ofthe plurality of electrodes and at least one of the signal received fromthe at least one optical sensor and the subcutaneous tissue impedancesignal; means for comparing the current tissue oxygen saturation value,the current tissue impedance value, and the current pulse transit timevalue to corresponding ones of a baseline tissue oxygenation saturationvalue, a baseline tissue impedance, and a baseline pulse transit timevalue; and means for determining the heart failure status of the patientbased on the comparison.

In another example, a non-transitory computer-readable medium storesinstructions for causing processing circuitry to perform a method fordetermining a heart failure status of a patient using an implantablemedical device configured for subcutaneous implantation outside of athorax of the patient, the implantable medical device comprising aplurality of electrodes and at least one optical sensor, the methodcomprising determining a current tissue oxygen saturation value of thepatient based on a signal received from the at least one optical sensor;determining a current tissue impedance value of the patient based on asubcutaneous tissue impedance signal received from a first at least twoof the plurality of electrodes; determining a current pulse transit timevalue of the patient based on a cardiac electrogram signal received froma second at least two of the plurality of electrodes and at least one ofthe signal received from the at least one optical sensor and thesubcutaneous tissue impedance signal; comparing the current tissueoxygen saturation value, the current tissue impedance value, and thecurrent pulse transit time value to corresponding ones of a baselinetissue oxygenation saturation value, a baseline tissue impedance, and abaseline pulse transit time value; and determining the heart failurestatus of the patient based on the comparison.

In another example, a system for determining a heart failure status of apatient comprises one or more sensors configured to monitor one or moreparameters of the patient; and processing circuitry configured to:determine current values of the one or more parameters of the patientbased on one or more signals received from the one or more sensors, theone or more parameters comprising a surrogate parameter for congestion,a surrogate parameter for tissue perfusion, and a surrogate parameterfor blood pressure; compare the current value of the surrogate parameterfor congestion, the current value of the surrogate parameter for tissueperfusion, and the current value of the surrogate parameter for bloodpressure to corresponding ones of a baseline value of the surrogateparameter for congestion, a baseline value of the surrogate parameterfor tissue perfusion, and a baseline value of the surrogate parameterfor blood pressure; and determine the heart failure status of thepatient based on the comparison.

This summary is intended to provide an overview of the subject matterdescribed in this disclosure. It is not intended to provide an exclusiveor exhaustive explanation of the apparatus and methods described indetail within the accompanying drawings and description below. Thedetails of one or more aspects of the disclosure are set forth in theaccompanying drawings and the description below.

BRIEF DESCRIPTION OF DRAWINGS

The details of one or more examples of this disclosure are set forth inthe accompanying drawings and the description below. Other features,objects, and advantages of this disclosure will be apparent from thedescription and drawings, and from the claims.

FIG. 1 is a conceptual drawing illustrating an example of a medicaldevice system including a leadless implantable medical device and anexternal device in conjunction with a patient;

FIG. 2 is a conceptual drawing illustrating an example configuration ofthe leadless implantable medical device of the medical device system ofFIG. 1;

FIG. 3 is a functional block diagram illustrating another perspective ofthe example configuration of the leadless implantable medical device ofFIG. 1;

FIGS. 4A and 4B are block diagrams illustrating other example leadlessimplantable medical devices substantially similar to the implantablemedical device of FIG. 1;

FIG. 5 is a block diagram illustrating an example system that includesan external device, such as a server, and one or more computing devicesthat are coupled to the leadless implantable medical device of FIG. 1and the external device of FIG. 1 via a network;

FIG. 6 is a flow diagram illustrating an example technique fordetermining a heart failure status of a patient based on a comparison ofcurrent tissue oxygen saturation, impedance, and pulse transit timevalues to corresponding baseline values, and transmitting the heartfailure status to a remote computer;

FIG. 7 is a flow diagram illustrating an example technique fordetermining the baseline or current values of tissue impedance, tissueoxygen saturation, and pulse transit time of FIG. 6;

FIG. 8 is a flow diagram illustrating an example technique fordetermining a current diagnostic score and determining an updated heartfailure status of a patient based on a comparison of the currentdiagnostic score to a baseline diagnostic score;

FIG. 9 is a flow diagram illustrating an example technique for a remotecomputer to determine instructions for a medical intervention based on aheart failure status received from the leadless implantable medicaldevice of FIG. 1, and transmit the instructions to a user interface;

FIG. 10 is a flow diagram illustrating an example technique fordetermining appropriate medical interventions for a hypervolemic patientbased on trends in the patient's tissue oxygen saturation and pulsetransit time;

FIG. 11 is a flow diagram illustrating an example technique fordetermining appropriate medical interventions for a hypovolemic patientbased on trends in the patient's tissue oxygen saturation and pulsetransit time; and

FIG. 12 is a flow diagram illustrating an example technique fordetermining appropriate medical interventions for an optivolemic patientbased on trends in the patient's tissue oxygen saturation and pulsetransit time.

DETAILED DESCRIPTION

In general, this disclosure describes example techniques related todetermining a heart failure status of a patient based on physiologicalparameters associated with cardiac function monitored by one or moremedical devices. A subcutaneous IMD may be used in some examples of thetechniques, and may be configured for placement under the skin of apatient's torso, such as between the skin and a pectoral muscle. In someexamples, processing circuitry may determine current Z, StO₂, and PTTvalues of the patient based on signals detected by a plurality ofelectrodes and one or more optical sensors, e.g., of the subcutaneousIMD. In some examples, the IMD may be leadless, and the optical sensorsand electrodes may be integrated with and/or connected to a housing ofthe IMD.

The processing circuitry may compare the current Z, StO₂, and PTT valuesto corresponding baseline values, which may be stored in a memory of theIMD. Based on differences between the current values and the baselinevalues, the processing circuitry may determine a current hemodynamicprofile of a heart failure status of the patient. For example, theprocessing circuitry may determine that a change in the patient'scardiac function and/or compensation status has occurred, and transmitthe heart failure status to a remote computer. It is furthercontemplated that, in some examples, the remote computer may transmitinstructions for medical intervention to a user device based on theheart failure status.

Techniques that monitor one or more aspects of cardiac function, such asby measuring transthoracic impedance and/or PTT, do not provide a robustassessment of a patient's heart failure status that may be obtained by acombined assessment of Z, StO₂, and PTT. Indeed, two patients withhemodynamic profile that vary by one of these three parameters may havedifferent heart failure statuses, and thus different treatmentrequirements. For example, the two patients each may have impedance andPTT values that reflect congestion and non-vasoconstriction. However, anStO₂ value of the first patient may reflect adequate peripheralperfusion, whereas an StO₂ value of the second patient may reflectinadequate peripheral perfusion. The hemodynamic profile of the firstpatient thus may be characterized as “warm and wet” (i.e., adequatelyperfused and congested), whereas the profile of the second patient is“cold and wet” (i.e., inadequately perfused and congested). Prognosisand the treatment requirements of these two patients differ based ontheir differing peripheral perfusion statuses. For example, the “coldand wet” patient may be at higher risk of acute decompensation andrequire a downward titration of a beta-blocker drug to help increaseheart rate, whereas a different treatment modification may be requiredfor the “warm and wet” patient. Thus, monitoring of only tissueimpedance and/or PTT may be inadequate to fully assess a patient's heartfailure status for the purpose of predicting adverse medical events(e.g., acute decompensation or hospitalization) and identifyingappropriate treatment options.

Various techniques for monitoring cardiac function may be more or lessinvasive and/or prone to inaccuracy. For example, sensing transthoracicimpedance values or producing an ECG with signals obtained fromelectrodes on leads placed within the thoracic cavity, such as withinthe heart, may be more invasive than sensing parameters, e.g., Z, StO₂,and PTT, via a subcutaneous 1 MB. Some methods may use electrodes oroptical sensors positioned at peripheral sites on the patient to monitorparameters such as PTT. However, values determined based on signals fromperipherally-located sensors may be more prone to motion artifactsgenerated by patient movement than values determined by sensors placedcentrally, e.g., subcutaneously outside the thorax. In addition,peripheral sensor based PTT measurement techniques may require multiplemeasuring devices to be synchronized together, which may provideadditional opportunities for measurement inaccuracy. Moreover, whileother methods for monitoring cardiac function may include generating analert if a measurement satisfies a threshold, a limitation of suchmethods is that they do not include providing instructions to thepatient for a medical intervention based on such alerts.

In some example techniques described herein, a patient's hemodynamicprofile and heart failure status may be determined using a subcutaneousimplantable device configured to measure all three of Z, StO₂, and PTTfrom a single location, which may be near a patient's pectoral muscle.Such measurements may be repeated at predetermined intervals, such ashourly or daily. The device then may determine a heart failure status ofthe patient based on current and baseline values of Z, StO₂, and PTT,and transmit the heart failure status via wireless communication to aremote computer, which then may transmit instructions for medicalintervention to a user device (e.g., a smartphone or tablet, locatedwith the patient or a caregiver). Thus, in some cases, the techniquesdescribed herein advantageously may provide robust and accurateassessment of a patient's heart failure status at regular intervals andenable modification of a patient's treatment between clinician visits,which in turn may provide improved clinical outcomes.

FIG. 1 illustrates the environment of an example medical device system 2in conjunction with a patient 4 and a heart 6, in accordance with anapparatus and method of certain examples described herein. The exampletechniques may be used with a leadless subcutaneously-implantablemedical device (IMD) 10, which may be in wireless communication withexternal device 12. In some examples, IMD 10 may be implanted outside ofa thoracic cavity of patient 4 (e.g., subcutaneously in the pectorallocation illustrated in FIG. 1). IMD 10 may be positioned near thesternum near or just below the level of heart 6, e.g., at leastpartially within the cardiac silhouette. In some examples, IMD 10 maytake the form of a Reveal LINQ™ Insertable Cardiac Monitor (ICM),available from Medtronic plc, of Dublin, Ireland. External device 12 maybe a computing device configured for use in settings such as a home,clinic, or hospital, and may further be configured to communicate withIMD 10 via wireless telemetry. For example, external device 12 may becoupled to a remote patient monitoring system, such as Carelink®,available from Medtronic plc, of Dublin, Ireland. External device 12may, in some examples, comprise a programmer, an external monitor, or aconsumer device such as a smart phone or tablet.

IMD 10 may include a plurality of electrodes and one or more opticalsensors, which collectively detect signals that enable processingcircuitry, e.g., of the IMD 10, to determine current values ofsubcutaneous Z, StO₂, and PTT for patient 4, and determine a heartfailure status of patient 4 based on such values. For example, theplurality of electrodes may be configured to detect a signal indicativeof a Z value of the extracellular or extra-vascular fluid in the tissuesurrounding and the IMD 10. Thus, in some examples, a Z value mayindicate the presence of peripheral edema as a consequence ofcongestion. Processing circuitry of IMD 10 may use the Z value of thetissue surrounding the IMD to determine a congestion status of patient4. In some examples, processing circuitry of IMD 10 also may use the Zvalue in conjunction with an ECG signal detected by the plurality ofelectrodes to determine a PTT value of patient 4. In other examples,processing circuitry of IMD 10 may use signals detected by one or moreoptical sensors positioned on a surface of IMD 10 to determine a PTTvalue in conjunction with the ECG signal. Processing circuitry of IMD 10also may use signals detected by the one or more optical sensors todetermine an StO₂ value of patient 4.

After determining current values for Z, StO₂, and PTT of patient 4,processing circuitry, e.g., of IMD 10, may compare such current valuesto corresponding baseline values, e.g., stored in a memory of IMD 10, todetermine differences therebetween. If the differences between one ormore of the current and corresponding baseline values satisfies athreshold, then the processing circuitry may determine that a heartfailure status of patient 4 has changed relative to a time when thebaseline values were established. Regardless of whether any suchdifferences satisfy a threshold, IMD 10 then may wirelessly transmit theheart failure status of patient 4 to external device 12. The heartfailure status may include a diagnostic score of patient 4, which may beassociated with a likelihood that patient 4 will acutely decompensateand require hospitalization within a certain period of time. IMD 10 maytransmit a heart failure status of patient 4 to external device 12 atpredetermined intervals, such as daily, weekly, or at any other desiredperiod.

In some examples, an interval at which IMD 10 determines a heart failurestatus of patient 4 is the same as an interval at which IMD 10 transmitsthe heart failure status to external device 12. In other examples, IMD10 may determine a heart failure status of patient 4 more frequentlythan IMD 10 transmits a heart failure status to external device 12. Bydetermining a heart failure status more often than a heart failurestatus is transmitted, an accuracy of a technique for determining aheart failure status may be enhanced by eliminating outliermeasurements. For example, IMD 10 may determine that a differencebetween a current Z, StO₂, or PTT of patient 4 and a correspondingbaseline satisfies a threshold only if a certain number or proportion ofpreceding results satisfied the threshold. In other examples, a singleincident in which a current value satisfied a threshold may suffice tocause IMD 10 to determine that a change in heart failure status ofpatient 4 has occurred. In some examples, a clinician may configure asensitivity of IMD 10 to certain types of values that satisfy athreshold at or after the time of implant of IMD 10, depending onfactors such as the individual condition of patient 4. As discussedbelow, several aspects of the operation of IMD 10 may be configured by aclinician to help achieve improved monitoring and clinical outcomes forindividual patients such as patient 4.

At or after the time of implantation of IMD 10 into the subcutaneouslocation illustrated in FIG. 1, a clinician may configure one or moreaspects of IMD 10. In some examples, a clinician may establish baselinevalues of Z, StO₂, and PTT using conventional assessments. For example,the clinician may use stethoscope to listen for congestion, conductarterial and venous blood draws with co-oximeter measurements to assessperfusion, and apply a blood pressure cuff to approximate vascularresistance. In addition, the clinician may complete a standardexamination and assessment of patient 4's congestion, peripheralperfusion, and vascular resistance statuses. For example, the clinicianmay identify whether, and to what extent, congestion is present. Theclinician then may use an application on a tablet or other smart deviceto enter empirically-determined baseline values of Z, StO₂, and PTT intoa memory of the IMD 10, along with patient 4's status with respect tocongestion, peripheral perfusion, and vascular resistance.

In other examples, instead of determining baseline values for Z, StO₂,and PTT using the conventional assessment noted above, a clinician mayconduct the standard examination and assessment of patient 4'scongestion, peripheral perfusion, and vascular resistance statuses.Based on the outcome of this assessment, and optionally on other datacorresponding to patient 4, the clinician may select baseline values ofZ, StO₂, and PTT for patient 4. Lists or tables of such values may bepresented by the app on the clinician tablet or other smart device, ormay be available from a centralized database. Once the clinician hasselected appropriate baseline values for patient 4, he or she may usethe app to store the values in IMD 10.

In still other examples, IMD 10 may be configured to undertake alearning phase after implantation into patient 4, in which IMD 10determines the baseline values of Z, StO₂, and PTT (where the baselinevalue PTT is determined based on a baseline cardiac electrogram signalplus a baseline optical signal or a baseline Z) for patient 4 based onvalues collected by IMD 10 over a period of time, and stores the valuesin a memory of IMD 10. For example, IMD 10 may measure Z, StO₂, and PTTon a relatively frequent basis (e.g., hourly or several times a day) fora period of time (e.g., a week or more) to determine baseline valuesduring a period when the condition of patient 4 is stable and notacutely decompensating.

Because heart failure is a progressive disease, values for baselines,thresholds, and event identifiers associated with patient 4 also may beupdated periodically. For example, IMD 10 may undertake a new learningphase monthly, quarterly, yearly, or at an expiration of any otherappropriate period. The new learning phase may produce new valuesassociated with one or more of the baselines, thresholds, and evidencelevels based on an updated heart failure status of patient 4. In otherexamples, a clinician may program IMD 10 to update such values asneeded, such as following a health event experienced by patient 4 thatmay affect the applicability of such values to patient 4's heart failurestatus.

In some examples, IMD 10 may determine baseline values based on averagesof the Z, StO₂, and PTT values collected during the training period. Inother examples, IMD 10 may reject outlier values collected during thetraining period prior to determining the baseline values, although IMDmay use other methods of determining baseline values from collectedvalues. In some examples in which IMD 10 uses a training period todetermine the baseline values, a clinician also may conduct the standardexamination and assessment of congestion, peripheral perfusion, andvascular resistance statuses of patient 4, and store the values in IMD10.

In addition to determining baseline values of Z, StO₂, and PTT forpatient 4, IMD 10 or a clinician also may determine threshold values ofZ, StO₂, and PTT for patient 4 and store the threshold values in amemory of IMD 10. In some examples, a threshold value may be indicativeof a value of a difference between a current value of one of Z, StO₂, orPTT and a corresponding baseline value that indicates that a heartfailure status of patient 4 may have changed. For example, adetermination by IMD 10 of a heart failure status of patient 4 may bebased, at least in part, on whether any of the differences between thecurrent values of Z, StO₂, or PTT and the corresponding baseline valuessatisfy a threshold value.

IMD 10 may determine threshold values for each of a number of differentbaseline values for each of Z, StO₂, and PTT, such as during thetraining period of IMD 10. In some examples, IMD 10 may automaticallyassociate a particular threshold value with a particular baseline valueof one of Z, StO₂, or PTT for patient 4. In other examples, IMD 10 maydetermine a threshold value for the one of Z, StO₂, or PTT based in parton the values of the other baselines determined for patient 4. Forexample, if a baseline Z value of patient 4 indicates that patient 4 iscongested, IMD 10 may select a lower threshold value for StO₂ than ifthe baseline Z value does not indicate that patient 4 is congested. Inthis way, IMD 10's determinations of heart failure status may be moresensitive for patients that are at a higher overall risk for acutedecompensation, or for whom acute decompensation may have greater healthconsequences. In other examples, a clinician may choose to program IMD10 to apply relatively higher or lower thresholds than those selected byprocessing circuitry of IMD 10 based on other considerations known tothe clinician.

Regardless of whether the threshold values for Z, StO₂, and PTT aredetermined by processing circuitry of IMD 10 during a training period orby a clinician, such threshold values may be updated at one or moretimes after implantation of IMD 10. For example, threshold values may beupdated after patient 4 experiences an acute decompensation orhospitalization event, which may indicate that one or more parameters ofa heart failure condition of patient 4 has progressed or otherwisechanged. Or, the threshold values may be updated at the expiration of atime period (e.g., weekly, monthly, or yearly following implantation ofIMD 10). Such updates to the threshold values may be performedautomatically by processing circuitry of IMD 10, or manually by aclinician. In any such examples, the updated threshold values may bedetermined based on trends in one or more of the current values of Z,StO₂, and PTT during the preceding time period. In this manner, thethreshold values used in the techniques described herein may be modifiedas needed to account for changes in patient 4's hemodynamic profile.

In addition to determining whether the differences between any currentvalues of Z, StO₂, or PTT and corresponding baseline values satisfy oneor more threshold values, IMD 10 also may determine a diagnostic scorefor patient 4 based on the current values of Z, StO₂, and PTT. Adiagnostic score may be a value (e.g., a numeric value) that isassociated with a likelihood that patient 4 will acutely decompensateand/or require hospitalization within a certain period of time,regardless of whether the differences between any current values of Z,StO₂, or PTT and corresponding baseline values satisfy one or morethreshold values. In some examples, a diagnostic score of patient 4 maybe further increased if one or more such differences satisfy a thresholdvalue.

IMD 10 may determine a diagnostic score of patient 4 based, at least inpart, on values of evidence levels that may be associated with values ofvarious parameters of heart failure. In some examples, such evidencelevels may be determined based on assessments of one or more populationsof patients with heart failure conditions. Diagnostic scores maycomprise one or more values associated with one or more evidence levels,with each evidence level being associated with a value of a parameter ofheart failure. For example, assessments of patient populations mayclassify parameters (e.g., congestion, inadequate perfusion,vasoconstriction/vasodilation) as occurring at varying levels ofseverity. Each level of severity of each parameter may be characterizedas an “evidence level” associated with a numerical value, and patientoutcomes (e.g., prior patient population data) for each evidence levelmay be documented. In light of patient outcomes, the numerical valuesassociated with the evidence levels may be weighted to reflect theirpredictive value of patient outcome.

IMD 10 may determine a diagnostic score associated with a heart failurestatus of patient 4 based on a combination of the evidence levelsassociated with the current values of Z, StO₂, and PTT of patient 4. Forexample, the diagnostic score may be based on an integration of priorpopulation data (e.g., data associated with the evidence levels) withmeasurements specific to patient 4 (e.g., the current values of Z, StO₂,or PTT of patient 4), such as by using Bayesian statistics or othermethods of machine learning. In some examples, an algorithm trainedusing clinician-scored, prior population data is applied topatient-specific measurements of parameters, such as the current valuesof Z, StO₂, or PTT, to determine a diagnostic score. In some examples, adiagnostic score determined based on a combination of evidence levelsmay indicate a likelihood that patient 4 underwent a change in each ofthe corresponding parameters of heart failure associated with theevidence levels. For example, an evidence level associated with acurrent value of Z may indicate an X % chance that patient 4 underwent achange in congestion status during a preceding time period on which thediagnostic score is based. Similarly, an evidence level associated witha current value of StO₂ or PTT may indicate a Y % or Z % chance thatpatient 4 underwent a change in respective ones of a tissue perfusion orblood pressure status during the preceding time period. In someexamples, the diagnostic score may be adjusted upward or downward basedon how many of the differences between the current values of patient 4and the corresponding baseline values satisfy associated thresholds. Inaddition, a clinician may manually modify weights assigned by IMD 10 toevidence levels for different measured parameters, depending on anindividual condition or medical history of patient 4. For example, theclinician may manually modify one or more of the weights assigned by IMD10 based on events in the medical history of patient 4 such as hospitaladmissions for heart failure, medication changes, history of systolicheart failure, hypertension, respiratory illness (e.g., COPD), diabetes,atrial fibrillation, renal failure, one or more blood disorders (e.g.,anemia), one or more sleep disorders (e.g., sleep apnea), among others.In any such examples, the evidence levels associated with the parametersof Z, StO₂, and PTT may be stored in a memory of IMD 10.

In some examples, a diagnostic score, as described above, may be abaseline diagnostic score associated with a heart failure status ofpatient 4. Because heart failure is a progressive disease, IMD 10periodically may determine an updated heart failure status of patient 4at regular intervals. In some examples, IMD 10 may determine an updatedheart failure status of patient 4 by iteratively performing the methodsdescribed above. In other examples, an updated heart failure status ofpatient 4 determined by IMD 10 may be based, at least in part, on adetermination of a current diagnostic score of patient 4 and acomparison of the current diagnostic score to a previously-determineddiagnostic score of patient 4 (e.g., a baseline diagnostic score).

In such examples, IMD 10 may determine a current diagnostic score ofpatient 4 by combining weighted values associated with the currentvalues of Z, StO₂, and PTT of patient 4. For example, IMD 10 maydetermine a difference between current values of each of Z, StO₂, andPTT and the corresponding baseline values of patient 4. IMD 10 then maydetermine a weighted value for each of the differences between thecurrent values and the corresponding baseline values. In some examples,IMD 10 may assign weights to the difference values based on factors suchas a medical history of patient 4, which may include one or more of themedical history events described above with respect to examples in whicha clinician manually modifies one or more of the weights. For example,patient 4 may have a medical history of becoming congested, which mayindicate that patient 4 is prone to becoming congested in the future.Or, population-based data may indicate that patients having a same orsimilar profile of baseline values as patient 4 may be particularlylikely to become congested (or inadequately perfused orvasoconstricted/vasodilated). In some examples, weights assigned by IMD10 to the difference values may have negative values, such as if amedical history of patient 4 or population-based data indicate thatpatient 4 is unlikely to become congested (or inadequately perfused orvasoconstricted/vasodilated). IMD 10 then may combine the weightedvalues of the differences between the current values and the baselinevalues, to arrive at a current diagnostic score for patient 4.

In some examples, IMD 10 may compare the current diagnostic score to thebaseline diagnostic score of patient 4, the latter of which may havebeen determined during a prior iteration of a method in which IMD 10determined a heart failure status of patient 4. IMD 10 then maydetermine an updated heart failure status of patient 4 based on thecomparison of the baseline diagnostic score to the current diagnosticscore, and transmit the updated heart failure status to a remotecomputer (e.g., external device 12). External device 12, or anotherremote computer, then may transmit instructions for a medicalintervention (e.g., a change in a drug regimen, or instructions toschedule a clinician visit or seek medical attention), to an interfaceof a user device located with patient 4.

In some examples, the baseline diagnostic score of patient 4 may beupdated, in a substantially similar manner as described above withrespect to the threshold values. For example, the baseline diagnosticscore of patient 4 may be updated after patient 4 experiences an acutedecompensation or hospitalization event, which may indicate that one ormore parameters of a heart failure condition of patient 4 has progressedor otherwise changed. In some examples, the baseline diagnostic score ofpatient 4 may be updated at the expiration of a time period (e.g.,weekly, monthly, or yearly following implantation of IMD 10). Suchupdates to the baseline diagnostic score of patient 4 may be performedautomatically by processing circuitry of IMD 10, or manually by aclinician.

As described above, the operating parameters of IMD 10 readily may becustomized to meet the needs of patient 4, such as by setting values ofbaselines, thresholds, and evidence levels based on the individualattributes of patient 4. The extent and ease of customizability of IMD10 may provide numerous benefits. For example, customizability of IMD 10to reflect a heart failure condition of patient 4 helps ensure thatappropriate drug therapies are prescribed for patient 4, therebyreducing a likelihood of human error in prescribing treatment. Inaddition, in examples in which IMD 10 selects one or more of thebaseline values, threshold values, or evidence level values for patient4, burdens on the clinician's time may be reduced, which may reduce thetime needed for an office visit and promote efficient treatment.Moreover, as discussed above, IMD 10 enables modification of heartfailure treatment for patient 4 in between clinician visits, which mayhelp avoid acute decompensation and thus lead to better clinicaloutcomes, such as improved quality of life for patient 4 or reducedmedical expenses.

External device 12 may be used to program commands or operatingparameters into IMD 10 for controlling its functioning (e.g., whenconfigured as a programmer for IMD 10). In some examples, externaldevice 12 may be used to interrogate IMD 10 to retrieve data, includingdevice operational data as well as physiological data accumulated in IMDmemory. Such interrogation may occur automatically according to aschedule, or may occur in response to a remote or local user command.Programmers, external monitors, and consumer devices are examples ofexternal devices 12 that may be used to interrogate IMD 10. Examples ofcommunication techniques used by IMD 10 and external device 12 includeradiofrequency (RF) telemetry, which may be an RF link established viaBluetooth, WiFi, or medical implant communication service (MICS). Insome examples, external device 12 may include a user interfaceconfigured to allow a clinician to remotely interact with IMD 10.

Medical system 2 is an example of a medical device system configured tomonitor a heart failure status of patient 4 and facilitate updates toheart-failure treatment of patient 4 as needed between clinician visits.The techniques described herein may be performed by processing circuitryof a device of medical system 2, such as processing circuitry of IMD 10.Additionally, or alternatively, the techniques described herein may beperformed, in whole or in part, by processing circuitry of externaldevice 12, and/or by processing circuitry of one or more other implantedor external devices or servers not shown. Examples of the one or moreother implanted or external devices may include a transvenous,subcutaneous, or extravascular pacemaker or implantablecardioverter-defibrillator (ICD), a blood analyzer, an external monitor,or a drug pump. The communication circuitry of each of the devices ofsystem 2 allows the devices to communicate with one another. Inaddition, although the optical sensors and electrodes are describedherein as being positioned on a housing of IMD 10, in other examples,such optical sensors and/or electrodes may be positioned on a housing ofanother device implanted in or external to patient 4, such as atransvenous, subcutaneous, or extravascular pacemaker or ICD, or coupledto such a device by one or more leads. For example, in cases in whichpatient 4 has an implanted pacemaker or ICD, the techniques describedherein may include sensing signals for determining Z with electrodes onthe pacemaker or ICD. In such examples, electrodes or one or moreoptical sensors for detecting signals associated with StO₂ and PTT maybe positioned on one or more external monitoring devices (e.g., awearable monitor). In such examples, one or more of the pacemaker/ICDand the one or more external monitoring devices may include processingcircuitry configured to receive signals from the electrodes or opticalsensors on the respective devices and/or communication circuitryconfigured to transmit the signals from the electrodes or opticalsensors to another device (e.g., external device 12) or server.

In some examples, medical system 2 may be configured to monitor one ormore parameters in addition to or instead of any of Z, StO₂, and PTT.For example, sensors on IMD 10 or one or more other implanted orexternal devices may be configured to sense signals associated with suchparameters. Such one or more parameters may be associated withphysiological functions of patient 4, such as kidney function, which maychange when a heart failure status of patient 4 changes. For example,one or more implanted or external devices of medical system 2 (e.g., IMD10) may include one or more sensors configured to sense blood or tissuelevels of one or more compounds associated with kidney function ofpatient 4, such as creatinine or blood urea nitrogen. In such examples,techniques for determining a heart failure status of patient 4 mayinclude determining, by processing circuitry of IMD 10, external device12, or one or more other implanted or external devices or servers, acurrent value of the one or more parameters in addition to or instead ofany of Z, StO₂, and PTT, comparing such a current value to acorresponding baseline, and using the comparison in determining theheart failure status of patient 4. In some examples, such one or moreparameters may not be directly associated with changes in a heartfailure status, but may provide other information about the health ofpatient 4, such as activity levels or sleep patterns.

FIGS. 2-4B illustrate various aspects and example arrangements of IMD 10of FIG. 1. For example, FIG. 2 conceptually illustrates an examplephysical configuration of IMD 10. FIG. 3 is a block diagram illustratingan example functional configuration of IMD 10. FIGS. 4A and 4Billustrate additional views of an example physical and functionalconfiguration of IMD 10. It should be understood that any of theexamples of IMD 10 described below with respect to FIGS. 2-4B may beused to implement the techniques described herein for determining aheart failure status of patient 4.

FIG. 2 is a conceptual drawing illustrating an example configuration ofIMD 10 of FIG. 1. In the example shown in FIG. 2, IMD 10 may comprise aleadless, subcutaneously-implantable monitoring device having housing14, proximal electrode 16A, and distal electrode 16B. Housing 14 mayfurther comprise first major surface 18, second major surface 20,proximal end 22, and distal end 24. In some examples, IMD 10 may includeone or more additional electrodes 16C, 16D positioned on one or both ofmajor surfaces 18,20 of IMD 10. Housing 14 encloses electronic circuitrylocated inside the IMD 10, and protects the circuitry contained thereinfrom fluids such as body fluids. In some examples, electricalfeedthroughs provide electrical connection of electrodes 16A-16D, andantenna 26, to circuitry within housing 14. In some examples, electrode16B may be formed from an uninsulated portion of conductive housing 14.

In the example shown in FIG. 2, IMD 10 is defined by a length L, a widthW, and thickness or depth D. In this example, IMD 10 is in the form ofan elongated rectangular prism in which length L is significantlygreater than width W, and in which width W is greater than depth D.However, other configurations of IMD 10 are contemplated, such as thosein which the relative proportions of length L, width W, and depth D varyfrom those described and shown in FIG. 2. In some examples, the geometryof the IMD 10, such as the width W being greater than the depth D, maybe selected to allow IMD 10 to be inserted under the skin of the patientusing a minimally invasive procedure and to remain in the desiredorientation during insertion. In addition, IMD 10 may include radialasymmetries (e.g., the rectangular shape) along a longitudinal axis ofIMD 10, which may help maintain the device in a desired orientationfollowing implantation.

In some examples, a spacing between proximal electrode 16A and distalelectrode 16B may range from about 30-55 mm, about 35-55 mm, or about40-55 mm, or more generally from about 25-60 mm. Overall, IMD 10 mayhave a length L of about 20-30 mm, about 40-60 mm, or about 45-60 mm. Insome examples, the width W of major surface 18 may range from about 3-10mm, and may be any single width or range of widths between about 3-10mm. In some examples, a depth D of IMD 10 may range from about 2-9 mm.In other examples, the depth D of IMD 10 may range from about 2-5 mm,and may be any single or range of depths from about 2-9 mm. In any suchexamples, IMD 10 is sufficiently compact to be implanted within thesubcutaneous space of patient 4 in the region of a pectoral muscle.

IMD 10, according to an example of the present disclosure, may have ageometry and size designed for ease of implant and patient comfort.Examples of IMD 10 described in this disclosure may have a volume of 3cubic centimeters (cm³) or less, 1.5 cm³ or less, or any volumetherebetween. In addition, in the example shown in FIG. 2, proximal end22 and distal end 24 are rounded to reduce discomfort and irritation tosurrounding tissue once implanted under the skin of patient 4. In someexamples, a configuration of IMD 10, including instrument and method forinserting IMD 10 is described, for example, in U.S. Patent PublicationNo. 2014/0276928, incorporated herein by reference in its entirety. Insome examples, a configuration of IMD 10 is described, for example, inU.S. Patent Publication No. 2016/0310031, incorporated herein byreference in its entirety.

In the example shown in FIG. 2, first major surface 18 of IMD 10 facesoutward towards the skin, when IMD 10 is inserted within patient 4,whereas second major surface 20 is faces inward toward musculature ofpatient 4. Thus, first and second major surfaces 18, 20 may face indirections along a sagittal axis of patient 4 (see FIG. 1), and thisorientation may be maintained upon implantation due to the dimensions ofIMD 10.

Proximal electrode 16A and distal electrode 16B may be used to sensecardiac EGM signals (e.g., ECG signals) when IMD 10 is implantedsubcutaneously in patient 4. In the techniques described herein,processing circuitry of IMD 10 may determine a PTT value based in parton cardiac ECG signals, as further described below. In some examples,processing circuitry of IMD 10 also may determine whether cardiac ECGsignals of patient 4 are indicative of arrhythmia or otherabnormalities, which processing circuitry of IMD 10 may evaluate indetermining whether a heart failure status of patient 4 has changed. Thecardiac ECG signals may be stored in a memory of the IMD 10, and dataderived from the cardiac ECG signals may be transmitted via integratedantenna 26 to another medical device, such as external device 12. Insome examples, one or both of electrodes 16A and 16B also may be used todetect subcutaneous impedance value Z for assessing a congestion statusof patient 4, and/or may be used by communication circuitry of IMD 10for TCC communication with external device 12.

In the example shown in FIG. 2, proximal electrode 16A is in closeproximity to proximal end 22, and distal electrode 16B is in closeproximity to distal end 24 of IMD 10. In this example, distal electrode16B is not limited to a flattened, outward facing surface, but mayextend from first major surface 18, around rounded edges 28 or endsurface 30, and onto the second major surface 20 in a three-dimensionalcurved configuration. As illustrated, proximal electrode 16A is locatedon first major surface 18 and is substantially flat and outward facing.However, in other examples not shown here, proximal electrode 16A anddistal electrode 16B both may be configured like proximal electrode 16Ashown in FIG. 2, or both may be configured like distal electrode 16Bshown in FIG. 2. In some examples, additional electrodes 16C and 16D maybe positioned on one or both of first major surface 18 and second majorsurface 20, such that a total of four electrodes are included on IMD 10.Any of electrodes 16A-16D may be formed of a biocompatible conductivematerial. For example, any of electrodes 16A-16D may be formed from anyof stainless steel, titanium, platinum, iridium, or alloys thereof. Inaddition, electrodes of IMD 10 may be coated with a material such astitanium nitride or fractal titanium nitride, although other suitablematerials and coatings for such electrodes may be used.

In the example shown in FIG. 2, proximal end 22 of IMD 10 includesheader assembly 32 having one or more of proximal electrode 16A,integrated antenna 26, anti-migration projections 34, and suture hole36. Integrated antenna 26 is located on the same major surface (e.g.,first major surface 18) as proximal electrode 16A, and may be anintegral part of header assembly 32. In other examples, integratedantenna 26 may be formed on the major surface opposite from proximalelectrode 16A, or, in still other examples, may be incorporated withinhousing 14 of IMD 10. Antenna 26 may be configured to transmit orreceive electromagnetic signals for communication. For example, antenna26 may be configured to transmit to or receive signals from a programmervia inductive coupling, electromagnetic coupling, tissue conductance,Near Field Communication (NFC), Radio Frequency Identification (RFID),Bluetooth, WiFi, or other proprietary or non-proprietary wirelesstelemetry communication schemes. Antenna 26 may be coupled tocommunication circuitry of IMD 10, which may drive antenna 26 totransmit signals to external device 12, and may transmit signalsreceived from external device 12 to processing circuitry of IMD 10 viacommunication circuitry.

IMD 10 may include several features for retaining IMD 10 in positiononce subcutaneously implanted in patient 4. For example, as shown inFIG. 2, housing 14 may include anti-migration projections 34 positionedadjacent integrated antenna 26. Anti-migration projections 34 maycomprise a plurality of bumps or protrusions extending away from firstmajor surface 18, and may help prevent longitudinal movement of IMD 10after implantation in patient 4. In other examples, anti-migrationprojections 34 may be located on the opposite major surface as proximalelectrode 16A and/or integrated antenna 26. In addition, in the exampleshown in FIG. 2 header assembly 32 includes suture hole 36, whichprovides another means of securing IMD 10 to the patient to preventmovement following insertion. In the example shown, suture hole 36 islocated adjacent to proximal electrode 16A. In some examples, headerassembly 32 may comprise a molded header assembly made from a polymericor plastic material, which may be integrated or separable from the mainportion of IMD 10.

Electrodes 16A and 16B may be used to sense cardiac ECG signals for PTTvalue determination, as described above. Additional electrodes 16C and16D may be used to sense subcutaneous tissue impedance (e.g., either formeasuring Z and/or for measuring PTT), in addition to or instead ofelectrodes 16A, 16B, in some examples. In some cases, it may beadvantageous to use separate electrode pairs for determining the currentZ and PTT values of patient 4. For example, using separate electrodes16A, 16B for impedance measurement and electrodes 16C, 16D for ECGsensing may help reduce a likelihood that a signal generated fordetermining a Z value may interfere with signals sensed by electrodes16C, 16D during the sensing of cardiac ECG signals. In addition, usingseparate electrode pairs for determining current Z and PTT values ofpatient 4 may better enable adaptation of one or more aspects ofelectrodes 16A-16D (e.g., size or spacing) to the assigned function ofeach electrode.

In some examples, processing circuitry of IMD 10 may determine a Z valueof patient 4 based on signals received from at least two of electrodes16A-16D. For example, processing circuitry of IMD 10 may generate one ofa current or voltage signal, deliver the signal via a selected two ormore of electrodes 16A-16D, and measure the resulting other of currentor voltage. Processing circuitry of IMD 10 may determine an impedancesignal based on the delivered current or voltage and the measuredvoltage or current.

In some examples, processing circuitry of IMD 10 may determine a PTTvalue of patient 4 based on the sensed ECG signal from electrodes 16A,16B and the current value of Z based on signals received from electrodes16C and 16D. For example, the processing circuitry of IMD 10 may receivethe ECG signal from electrodes 16A, 16B, and identify one or morefeatures of a cardiac cycle within the ECG signal. The processingcircuitry may identify an R wave within a cardiac cycle, and associate afirst time (T1) with the occurrence of the R wave. Next, the processingcircuitry may identify a fluctuation in the subcutaneous tissueimpedance signal occurring after T1, and associate a second time (T2)with the fluctuation, which may represent the passing of blood ejectedduring the observed cardiac cycle through the portion of the vasculaturenear electrodes 16C, 16D. By subtracting T2 from T1, processingcircuitry of IMD 10 then may determine a PTT value (e.g., inmilliseconds) of patient 4. To enable IMD 10 to accurately identifyfluctuations in PTT values of patient 4, it may be beneficial for aclinician to implant IMD 10 substantially as shown in FIG. 1, with atleast a portion of IMD 10 positioned at or inferior to heart 6. In thisway, IMD 10 may be positioned at a sufficient circulatory distance fromheart 6 to detect even small fluctuations in PTT, which may help IMD 10to accurately assess a heart failure status of patient 4.

In some other examples, techniques for determining PTT may include usinglight emitter 38 to emit light at one or more wavelengths, e.g., one ormore visible (VIS) wavelengths (e.g., approximately 600 nanometers (nm))and/or one or more near-infrared (NIR) wavelengths (e.g., approximately850-890 nm) in addition to the sensed ECG signal from electrodes 16A,16B. In such examples, processing circuitry of IMD 10 controls lightemitter 38 to emit light at the one or more wavelengths, such as a NIRor VIS wavelength, and concurrently monitor the sensed ECG signal. Theprocessing circuitry may identify an R wave within a cardiac cycle andassociate a first time (T1) with the occurrence of the R wave. Next, theprocessing circuitry may identify a fluctuation in the light detected bylight detectors 40A, 40B occurring after T1, and associate a second time(T2) with the fluctuation, which may represent the passing of bloodejected during the observed cardiac cycle through the portion of thevasculature near light detectors 40A, 40B. By subtracting T2 from T1,processing circuitry of IMD 10 then may determine a PTT value (e.g., inmilliseconds) of patient 4.

In the example shown in FIG. 2, IMD 10 includes a light emitter 38, aproximal light detector 40A, and a distal light detector 40B positionedon housing 14 of IMD 10. Light detector 40A may be positioned at adistance S from light emitter 38, and a distal light detector 40Bpositioned at a distance S+N from light emitter 38. In other examples,IMD 10 may include only one of light detectors 40A, 40B, or may includeadditional light emitters and/or additional light detectors.Collectively, light emitter 38 and light detectors 40A, 40B may comprisean optical sensor, which may be used in the techniques described hereinto determine StO₂ or PTT values of patient 4. Although light emitter 38and light detectors 40A, 40B are described herein as being positioned onhousing 14 of IMD 10, in other examples, one or more of light emitter 38and light detectors 40A, 40B may be positioned, on a housing of anothertype of IMD within patient 4, such as a transvenous, subcutaneous, orextravascular pacemaker or ICD, or connected to such a device via alead. Light emitter 38 includes a light source, such as an LED, that mayemit light at one or more wavelengths within the (VIS) and/or (NIR)spectra. For example, light emitter 38 may emit light at one or more ofabout 660 (nm), 720 nm, 760 nm, 800 nm, or at any other suitablewavelengths.

In some examples, techniques for determining StO₂ may include usinglight emitter 38 to emit light at one or more VIS wavelengths (e.g.,approximately 600 nm) and at one or more NIR wavelengths (e.g.,approximately 850-890 nm). The combination of VIS and NIR wavelengthsmay help enable processing circuitry of IMD 10 to distinguish oxygenatedhemoglobin from deoxygenated hemoglobin in the tissue of patient 4,because oxygenated hemoglobin absorbs more NIR light than VIS light,whereas deoxygenated hemoglobin absorbs more VIS light than NIR light.By comparing the amount of VIS light detected by light detectors 40A,40B to the amount of NIR light detected by light detectors 40A, 40B,processing circuitry of IMD 10 may determine the relative amounts ofoxygenated and deoxygenated hemoglobin in the tissue of patient 4. Forexample, if the amount of oxygenated hemoglobin in the tissue of patient4 decreases, the amount of VIS light detected by light detectors 40A,40B increases and the amount of NIR light detected by light detectors40A, 40B decreases. Similarly, if the amount of oxygenated hemoglobin inthe tissue of patient 4 increases, the amount of VIS light detected bylight detectors 40A, 40B decreases and the amount of NIR light detectedby light detectors 40A, 40B increases.

As shown in FIG. 2, light emitter 38 may be positioned on headerassembly 32, although, in other examples, one or both of light detectors40A, 40B may additionally or alternatively be positioned on headerassembly 32. In some examples, light emitter 38 may be positioned on amedial section of IMD 10, such as part way between proximal end 22 anddistal end 24. Although light emitter 38 and light detectors 40A, 40Bare illustrated as being positioned on first major surface 18, lightemitter 38 and light detectors 40A, 40B alternatively may be positionedon second major surface 20. In some examples, IMD may be implanted suchthat light emitter 38 and light detectors 40A, 40B face inward when IMD10 is implanted, toward the muscle of patient 4, which may help minimizeinterference from background light coming from outside the body ofpatient 4. Light detectors 40A, 40B may include a glass or sapphirewindow, such as described below with respect to FIG. 4B, or may bepositioned beneath a portion of housing 14 of IMD 10 that is made ofglass or sapphire, or otherwise transparent or translucent.

Light emitter 38 may emit light into a target site of patient 4 during atechnique for determining an StO₂ value of patient 4. The target sitemay generally include the interstitial space around IMD 10 when IMD 10is implanted in patient 4. Light emitter 38 may emit light directionallyin that light emitter may direct the signal to a side of IMD 10, such aswhen light emitter 38 is disposed on the side of IMD 10 that includesfirst major surface 18. The target site may include the subcutaneoustissue adjacent IMD 10 within patient 4. In one example, light emitter38 may deliver 180-degree light signals, such as 180 degrees along adimension parallel to a longitudinal axis of IMD 10. In some examples, alight signal may be a cloud of light generally directed inward, towardthe musculature and away from the skin of patient 4. In some examples,the light signal may take the mean free path, as the light signal may benon-directional once emitted from light emitter 38.

Techniques for determining an StO₂ value may be based on the opticalproperties of blood-perfused tissue that change depending upon therelative amounts of oxygenated and deoxygenated hemoglobin in themicrocirculation of tissue. These optical properties are due, at leastin part, to the different optical absorption spectra of oxygenated anddeoxygenated hemoglobin. Thus, the oxygen saturation level of thepatient's tissue may affect the amount of light that is absorbed byblood within the tissue adjacent IMD 10, and the amount of light that isreflected by the tissue. Light detectors 40A, 40B each may receive lightfrom light emitter 38 that is reflected by the tissue, and generateelectrical signals indicating the intensities of the light detected bylight detectors 40A, 40B. Processing circuitry of IMD 10 then mayevaluate the electrical signals from light detectors 40A, 40B in orderto determine an StO₂ value of patient 4.

In some examples, a difference between the electrical signals generatedby light detectors 40A, 40B may enhance an accuracy of the StO₂ valuedetermined by IMD 10. For example, because tissue absorbs some of thelight emitted by light emitter 38, the intensity of the light reflectedby tissue becomes attenuated as the distance (and amount of tissue)between light emitter 38 and light detectors 40A, 40B increases. Thus,because light detector 40B is positioned further from light emitter 38(at distance S+N) than light detector 40A (at distance S), the intensityof light detected by light detector 40B should be less than theintensity of light detected by light detector 40A. Due to the closeproximity of detectors 40A, 40B to one another, the difference betweenthe intensity of light detected by detector 40A and the intensity oflight detected by detector 40B should be attributable only to thedifference in distance from light emitter 38. In some examples,processing circuitry of IMD 10 may use the difference between theelectrical signals generated by light detectors 40A, 40B, in addition tothe electrical signals themselves, in determining an StO₂ value ofpatient 4.

As noted above, light emitter 38 and one or both of light detectors 40A,40B also may be used in a technique for determining a PTT value ofpatient 4. As with techniques for determining PTT in which processingcircuitry of IMD 10 receives a subcutaneous tissue impedance signal froma plurality of electrodes 16A-16D, techniques for determining PTT thatinclude using an optical sensor include identifying one or more featureswithin a cardiac cycle of patient 4, and associating a first time T1with an occurrence in the cardiac cycle. Instead of determining a secondtime T2 based on an impedance signal, however, IMD 10 may determine T2by identifying a fluctuation in the intensity and/or wavelength of lightdetected by one or both of light detectors 40A, 40B occurring after T1,and associate the second time (T2) with the fluctuation, which mayrepresent the passing of blood ejected during the cardiac cycle throughthe portion of the vasculature near the light detectors 40A, 40B. Bysubtracting T2 from T1, processing circuitry of IMD 10 then maydetermine a PTT value (e.g., in milliseconds) of patient 4.

In some examples, IMD 10 may include one or more additional sensors,such as one or more accelerometers (not shown). Such accelerometers maybe 3D accelerometers configured to generate signals indicative of one ormore types of movement of the patient, such as gross body movement(e.g., activity) of the patient, patient posture, movements associatedwith the beating of the heart, or coughing, rales, or other respirationabnormalities. In some examples, one or more of such accelerometers maybe used, in conjunction with light emitter 38 and optical detectors 40A,40B, to determine a ballistocardiogram (i.e., a measure of motioncorresponding to blood ejection at systole) that processing circuitry ofIMD 10 may use to determine PTT instead of or in addition to an ECGsignal from a pair of electrodes 16A-16D. Additionally, oralternatively, one or more of the parameters monitored by IMD 10 (i.e.,Z, StO₂, or PTT) may fluctuate in response to changes in one or moresuch types of movement. For example, changes in Z, StO₂, or PTT valuessometimes may be attributable to increased patient activity (e.g.,exercise or other physical activity as compared to inactivity) or tochanges in patient posture, and not necessarily to changes in a heartfailure status caused by a progression of a heart failure condition.Thus, in some methods of determining a heart failure status of patient4, it may be advantageous to account for such fluctuations whendetermining whether a change in a parameter, such as Z, StO₂, or PTT,that exceeds a threshold is indicative of a change in a correspondingone of a congestion status, a tissue perfusion status, or a bloodpressure status of patient 4.

In such examples, processing circuitry of IMD 10 may receive one or moresignals from one or more accelerometers of IMD 10, and determine a valueof one or more patient-activity parameters, such as gross body movement.In this example, processing circuitry of IMD 10 may cross-reference thedetermined patient-activity value with values of one or more otherparameters, such as a Z, StO₂, or PTT value. If the patient-activityvalue satisfies a threshold, processing circuitry of IMD 10 maydetermine that a change in a current a Z, StO₂, or PTT value thatotherwise may indicate a change in a heart failure status does notindicate a change in a congestion, tissue perfusion, or blood pressurestatus of patient 4. In such instances, processing circuitry of patient4 may designate the current value as an outlier and not use it indetermining a heart failure status of patient 4. In some examples,processing circuitry of IMD 10 may cross-reference the determinedactivity or posture values with different scaling factors to be appliedthe Z, StO₂, or PTT values prior to comparison to a threshold, or todifferent threshold values to which to compare the measured Z, StO₂, orPTT values. Although processing circuitry of IMD 10 is described aboveas being configured to receive signals from one or more accelerometers,electrodes 16A-16D, light emitter 38, and/or light detectors 40A, 40B ofIMD 10 and determine a value of one or more parameters of patient 4based on such signals, any steps described herein as being carried outby processing circuitry of IMD 10 may carried out by processingcircuitry of one or more devices. For example, processing circuitry ofexternal device 12, or any other suitable implantable or external deviceor server, may be configured to receive signals from the one or moreaccelerometers, electrodes 16A-16D, light emitter 38, and/or lightdetectors 40A, 40B of IMD 10, such as via communication circuitry of IMD10.

FIG. 3 is a functional block diagram illustrating an exampleconfiguration of IMD 10 of FIGS. 1 and 2. In the illustrated example,IMD 10 includes processing circuitry 50 sensing circuitry 52,communication circuitry 54, memory 56, switching circuitry 58, sensors62, timing/control circuitry 64, in addition to previously-describedelectrodes 16A-16D, one or more of which may be disposed within housing14 of IMD 10, and light emitter 38. In some examples, memory 56 includescomputer-readable instructions that, when executed by processingcircuitry 50, cause IMD 10 and processing circuitry 50 to performvarious functions attributed to IMD 10 and processing circuitry 50herein. Memory 56 may include any volatile, non-volatile, magnetic,optical, or electrical media, such as a random access memory (RAM),read-only memory (ROM), non-volatile RAM (NVRAM), electrically-erasableprogrammable ROM (EEPROM), flash memory, or any other digital media.

Processing circuitry 50 may include fixed function circuitry and/orprogrammable processing circuitry. Processing circuitry 50 may includeany one or more of a microprocessor, a controller, a digital signalprocessor (DSP), an application specific integrated circuit (ASIC), afield-programmable gate array (FPGA), or equivalent discrete or analoglogic circuitry. In some examples, processing circuitry 50 may includemultiple components, such as any combination of one or moremicroprocessors, one or more controllers, one or more DSPs, one or moreASICs, or one or more FPGAs, as well as other discrete or integratedlogic circuitry. The functions attributed to processing circuitry 50herein may be embodied as software, firmware, hardware or anycombination thereof.

Timing and control circuitry 64 may be embodied as hardware, firmware,software, or any combination thereof. In some examples, timing andcontrol circuitry 64 may comprise a dedicated hardware circuit, such asan ASIC, separate from other processing circuitry 50 components, such asa microprocessor, or a software module executed by a component ofprocessing circuitry 50 (e.g., a microprocessor or ASIC). Timing andcontrol circuitry 64 may monitor the passage of time to determine when amonitoring period has elapsed, and help control IMD 10 to measurecurrent values of Z, StO₂, and PTT of patient 4. Timing and controlcircuitry 64 also may control IMD 10 to transmit a heart failure statusof patient 4 to external device 12, at the conclusion of a correspondinginterval.

In some examples, timing and control circuitry 64 may be configured toassociate current values of Z, StO₂, and PTT with a particular time ofday, such as day time or night time, so as to enable processingcircuitry 50 to take into account a circadian rhythm of patient 4 whendetermining congestion, tissue perfusion, and/or blood pressure statusesof patient 4. For example, one or more of the values of Z, StO₂, and PTTvalues of patient 4 generally may decrease when patient 4 is asleep(e.g., nighttime), and increase when patient 4 is awake (e.g., daytime).Thus, IMD 10 may be configured to use different (e.g., lower) baselinevalue and/or threshold values for a particular parameter at times whenpatient 4 is likely to be asleep than when patient 4 is likely to beawake. In some examples in which IMD 10 includes one or moreaccelerometers, processing circuitry 50 may cross-reference a time ofday indicated by timing and control circuitry with accelerometer data,such as to confirm whether patient 4 is asleep or awake as predictedbased on the time of day. In this manner, timing and control circuitry64 may enhance the ability of IMD 10 to accurately determine a heartfailure status of patient 4.

In addition to sensed physiological parameters of patient 4 (e.g.,determined values of Z, StO₂, and PTT), one or more time intervals fortiming the measurements of Z, StO₂, and PTT by processing circuitry 50may be stored by memory 56 in stored measurements/intervals 68. Forexample, the intervals 68 stored by memory 56 may instruct processingcircuitry 50 to measure current values of Z, StO₂, and PTT of patient 4hourly, several times daily, daily, or at any other appropriateinterval. Stored measurements/intervals 68 also may include intervals atwhich processing circuitry may be configured to transmit a heart failurestatus of patient 4 to external device 12, such as daily, weekly, or atany other suitable interval. In some examples, processing circuitry 50may select intervals for measuring Z, StO₂, and PTT or for transmittinga heart failure status of patient 4 from stored measurements/intervals68. In other examples, a clinician may select interval values dependingupon the needs of patient 4, such as by using an application on a tabletor other smart device, which in some examples may be external device 12.

As illustrated in FIG. 3, memory 56 also may include one or more tables70 for storing baseline, threshold, and evidence level values. Asdescribed above, in some examples, processing circuitry 50 of IMD 10 maybe configured to determine baseline values of Z, StO₂, and PTT during alearning phase of IMD 10, which then may be stored in tables 70. Inaddition, tables 70 may include pre-programmed baseline values that aclinician may select for patient 4 during setup of IMD 10, or baselinevalues that a clinician may manually enter based on the clinician'sassessments of patient 4. Processing circuitry 50 also may be configuredto determine threshold values for deviations of current values of Z,StO₂, and PTT from the baseline values, and store the threshold valuesin tables 70. In some examples, processing circuitry 50 may determinesuch threshold values based, at least in part, on baseline valuesselected for patient 4. In addition to the baseline values, tables 70may include threshold values that a clinician may select for patient 4during setup of IMD 10, or threshold values that a clinician maymanually enter based on the clinician's assessments of patient 4. Tables70 also may include values for evidence levels that may be associatedwith certain values of Z, StO₂, or PTT that may be used by processingcircuitry 50 to determine a diagnostic score of patient 4. As describedabove, a heart failure status may comprise a diagnostic score of patient4, which in some examples may be a composite diagnostic score based on acombination of values of evidence levels associated with one or morecurrent values of Z, StO₂, and PTT of patient 4.

Sensing circuitry 52 and communication circuitry 54 may be selectivelycoupled to electrodes 16A-16D via switching circuitry 58, as controlledby processing circuitry 50. Sensing circuitry 52 may monitor signalsfrom electrodes 16A-16D in order to monitor electrical activity of heart(e.g., to produce an ECG for PTT determination), and/or subcutaneoustissue impedance Z (e.g., as a measure of congestion or for PTTdetermination). Sensing circuitry 52 also may monitor signals fromsensors 62, which may include light detectors 40A, 40B, and anyadditional light detectors that may be positioned on IMD 10. In someexamples, sensing circuitry 52 may include one or more filters andamplifiers for filtering and amplifying signals received from one ormore of electrodes 16A-16D and/or light detectors 40A, 40B.

In some examples, processing circuitry 50 also may include a rectifier,filter and/or amplifier, a sense amplifier, comparator, and/oranalog-to-digital converter. Upon receiving signals from electrodes16A-16D and light detectors 40A, 40B via sensing circuitry 52,processing circuitry 50 may determine current values for each of Z,StO₂, and PTT for patient 4. Processing circuitry then may compare thecurrent values of Z, StO₂, and PTT to the baseline levels stored intables 70, and determine whether differences between the current valuesand the corresponding baseline levels satisfy corresponding thresholdsstored in tables 70.

The threshold values stored in tables 70 may be associated with changesin certain parameters of a heart failure status of patient 4. Forexample, a threshold value corresponding to the Z value may beassociated with a change in a congestion status of patient 4, whereas athreshold value corresponding to the StO₂ value may be associated with achange in a tissue perfusion status of patient 4, and a threshold valuecorresponding to the PTT value may be associated with a change in avascular resistance or blood pressure status of patient 4. In someexamples, processing circuitry 50 may identify evidence level valuesassociated with the current values of Z, StO₂, and PTT of patient 4, anddetermine a diagnostic score associated with a combination of theevidence levels. Processing circuitry 50 may store the determinedcurrent values, associated evidence levels, and diagnostic scores instored measurements/intervals 68 of memory 56, along with an indicationof a date and time of the measurements. Simultaneously or thereafter,processing circuitry 50 may transmit, via communication circuitry 54,the diagnostic score and/or one or more additional indicators of a heartfailure status of patient 4 to external device 12.

Communication circuitry 54 may include any suitable hardware, firmware,software or any combination thereof for communicating with anotherdevice, such as external device 12 or another IMD or sensor, such as apressure sensing device. Under the control of processing circuitry 50,communication circuitry 54 may receive downlink telemetry from, as wellas send uplink telemetry to, external device 12 or another device withthe aid of an internal or external antenna, e.g., antenna 26. In someexamples, communication circuitry 54 may communicate with externaldevice 12. In addition, processing circuitry 50 may communicate with anetworked computing device via external device (e.g., external device12) and a computer network, such as the Medtronic CareLink® Networkdeveloped by Medtronic, plc, of Dublin, Ireland.

A clinician or other user may retrieve data from IMD 10 using externaldevice 12, or by using another local or networked computing deviceconfigured to communicate with processing circuitry 50 via communicationcircuitry 54. The clinician may also program parameters of IMD 10 usingexternal device 12 or another local or networked computing device. Insome examples, the clinician may select baseline values, thresholdvalues, times of day for Z, StO₂, and PTT measurements, or a number ofmeasurements to be completed during a period, e.g., day, and may programevidence levels to be associated with the parameters of Z, StO₂, andPTT.

The various components of IMD 10 may be coupled a power source, whichmay include a rechargeable or non-rechargeable battery positioned withinhousing 14 of IMD 10. A non-rechargeable battery may be selected to lastfor several years, while a rechargeable battery may be inductivelycharged from an external device, e.g., on a daily or weekly basis.

FIGS. 4A and 4B illustrate two additional example IMDs that may besubstantially similar to IMD 10 of FIGS. 1-3, but which may include oneor more additional features. The components of FIGS. 4A and 4B may notnecessarily be drawn to scale, but instead may be enlarged to showdetail. FIG. 4A is a block diagram of a top view of an exampleconfiguration of an IMD 10A. FIG. 4B is a block diagram of a side viewof example IMD 10B, which may include an insulative layer as describedbelow.

FIG. 4A is a conceptual drawing illustrating another example IMD 10Athat may be substantially similar to IMD 10 of FIG. 1. In addition tothe components illustrated in FIGS. 1-3, the example of IMD 10illustrated in FIG. 4A also may include a body portion 72 and anattachment plate 74. Attachment plate 74 may be configured tomechanically couple header 32 to body portion 72 of IMD 10A. Bodyportion 72 of IMD 10A may be configured to house one or more of theinternal components of IMD 10 illustrated in FIG. 3, such as one or moreof processing circuitry 50, sensing circuitry 52, communicationcircuitry 54, memory 56, switching circuitry 58, internal components ofsensors 62, and timing control circuitry 64. In some examples, bodyportion 72 may be formed of one or more of titanium, ceramic, or anyother suitable biocompatible materials.

FIG. 4B is a conceptual drawing illustrating another example IMD 10Bthat may include components substantially similar to IMD 10 of FIG. 1.In addition to the components illustrated in FIGS. 1-3, the example ofIMD 10B illustrated in FIG. 4B also may include a wafer-scale insulativecover 76, which may help insulate electrical signals passing betweenelectrodes 16A-16D and/or optical detectors 40A, 40B on housing 14B andprocessing circuitry 50. In some examples, insulative cover 76 may bepositioned over an open housing 14 to form the housing for thecomponents of IMD 10B. One or more components of IMD 10B (e.g., antenna26, light emitter 38, light detectors 40A, 40B, processing circuitry 50,sensing circuitry 52, communication circuitry 54, switching circuitry58, and/or timing/control circuitry 64) may be formed on a bottom sideof insulative cover 76, such as by using flip-chip technology.Insulative cover 76 may be flipped onto a housing 14B. When flipped andplaced onto housing 14B, the components of IMD 10B formed on the bottomside of insulative cover 76 may be positioned in a gap 78 defined byhousing 14B.

Insulative cover 76 may be configured so as not to interfere with theoperation of IMD 10B. For example, one or more of electrodes 16A-16D maybe formed or placed above or on top of insulative cover 76, andelectrically connected to switching circuitry 58 through one or morevias (not shown) formed through insulative cover 76. In addition, toenable IMD to determine values of StO₂ and PTT, at least a portion ofinsulative cover 76 may transparent to the NIR or visible wavelengthsemitted by light emitter 38 and detected by light detectors 40A, 40B,which in some examples may be positioned on a bottom side of insulativecover 76 as described above.

In some examples, light emitter 38 may include an optical filter betweenlight emitter 38 and insulative cover 76, which may limit the spectrumof emitted light to be within a narrow band. Similarly, light detectors40A, 40B may include optical filters between light detectors 40A, 40Band insulative cover 76, so that light detectors 40A, 40B detects lightfrom a narrow spectrum, generally at longer wavelengths than the emittedspectrum. Other optical elements that may be included in the IMD 10B mayinclude index matching layers, antireflective coatings, or opticalbarriers, which may be configured to block light emitted sideways by thelight emitter 38 from reaching light detector 40.

Insulative cover 76 may be formed of sapphire (i.e., corundum), glass,parylene, and/or any other suitable insulating material. Sapphire may begreater than 80% transmissive for wavelengths in the range of about 300nm to about 4000 nm, and may have a relatively flat profile. In the caseof variation, different transmissions at different wavelengths may becompensated for, such as by using a ratiometric approach. In someexamples, insulative cover 76 may have a thickness of about 300micrometers to about 600 micrometers. Housing 14B may be formed fromtitanium or any other suitable material (e.g., a biocompatiblematerial), and may have a thickness of about 200 micrometers to about500 micrometers. These materials and dimensions are examples only, andother materials and other thicknesses are possible for devices of thisdisclosure.

FIG. 5 is a functional block diagram illustrating an example system thatincludes an access point 90, a network 92, external computing devices,such as a server 94, and one or more other computing devices 100A-100N,which may be coupled to IMD 10, sensing device 12, and external device12 via network 92. In this example, IMD 10 may use communication module54 to communicate with external device 12 via a first wirelessconnection, and to communication with an access point 90 via a secondwireless connection. In the example of FIG. 5, access point 90, externaldevice 12, server 94, and computing devices 100A-100N are interconnectedand may communicate with each other through network 92.

Access point 90 may comprise a device that connects to network 92 viaany of a variety of connections, such as telephone dial-up, digitalsubscriber line (DSL), or cable modem connections. In other examples,access point 90 may be coupled to network 92 through different forms ofconnections, including wired or wireless connections. In some examples,access point 90 may be a user device, such as a tablet or smartphone,that may be co-located with the patient. As discussed above, IMD 10 maybe configured to transmit data, such as current values and heart failurestatuses, to external device 12. In addition, access point 90 mayinterrogate IMD 10, such as periodically or in response to a commandfrom the patient or network 92, in order to retrieve current values orheart failure statuses determined by processing circuitry 50 of IMD 10,or other operational or patient data from IMD 10. Access point 90 maythen communicate the retrieved data to server 94 via network 92.

In some cases, server 94 may be configured to provide a secure storagesite for data that has been collected from IMD 10, and/or externaldevice 12. In some cases, server 94 may assemble data in web pages orother documents for viewing by trained professionals, such asclinicians, via computing devices 100A-100N. One or more aspects of theillustrated system of FIG. 5 may be implemented with general networktechnology and functionality, which may be similar to that provided bythe Medtronic CareLink® Network developed by Medtronic plc, of Dublin,Ireland.

In some examples, one or more of computing devices 100A-100N (e.g.,device 100A) may be a tablet or other smart device located with aclinician, by which the clinician may program, receive alerts from,and/or interrogate IMD 10. For example, the clinician may access patient4's Z, StO₂, and PTT measurements through device 100A, such as whenpatient 4 is in in between clinician visits, to check on a heart failurestatus of patient 4 as desired. In some examples, the clinician mayenter instructions for a medical intervention for patient 4 into an appin device 100A, such as based on a heart failure status of patient 4determined by IMD 10, or based on other patient data known to theclinician. Device 100A then may transmit the instructions for medicalintervention to another of computing devices 100A-100N (e.g., device100B) located with patient 4 or a caregiver of patient 4. For example,such instructions for medical intervention may include an instruction tochange a drug dosage, timing, or selection, to schedule a visit with theclinician, or to seek medical attention. In further examples, device100B may generate an alert to patient 4 based on a heart failure statusof patient 4 determined by IMD 10, which may enable patient 4proactively to seek medical attention prior to receiving instructionsfor a medical intervention. In this manner, patient 4 may be empoweredto take action, as needed, to address his or her heart failure status,which may help improve clinical outcomes for patient 4.

FIGS. 6-12 are flow diagrams illustrating various techniques related todetermining a heart failure status of a patient based on a comparison ofcurrent Z, StO₂, and PTT values of the patient to corresponding baselinevalues, in accordance with examples of this disclosure. As describedherein, the techniques illustrated FIGS. 6-12 may be employed using oneor more components of system 2, which have been described above withrespect to FIGS. 1-5. Although described as being performed by IMD 10,the techniques of FIGS. 6-12 may be performed, in whole or in part, byprocessing circuitry and memory of other devices of a medical devicesystem, as described herein. For example, although processing circuitry50 of IMD is described as carrying out most of the example techniquesillustrated in FIGS. 6-9 for the sake of clarity, in other examples, oneor more devices (e.g., external device 12 or other external device orserver) or a clinician may carry out one or more steps attributed belowto processing circuitry 50 of IMD 10.

FIG. 6 is a flow diagram illustrating an example technique fordetermining, by processing circuitry 50 of IMD 10, a heart failurestatus of patient 4 based on a comparison of current tissue oxygensaturation, impedance, and pulse transit time values (i.e., Z, StO₂, andPTT) of patient 4 to corresponding baseline values stored in tables 70of memory 56, and transmitting the heart failure status to remote device12. According to the example of FIG. 6, IMD 10 may determine baseline Z,StO₂, and PTT values for patient 4 (110). In some examples, IMD 10 maydetermine the baseline values during a learning phase of IMD 10following implantation of IMD 10 into patient 4, as discussed above withrespect to FIG. 1. Such a learning phase may take place afterimplantation of IMD 10 at a time that a heart failure condition ofpatient 4 is stable (e.g., compensated).

During the learning phase, IMD 10 periodically may determine currentvalues of Z, StO₂, and PTT of patient 4 based on signals received fromone or more of electrodes 16A-16D, light emitter 38, and light detectors40A, 40B and store the values in stored measurements/intervals 68. IMD10 then may analyze the collected values of Z, StO₂, and PTT todetermine the baseline values for patient 4. In some examples, IMD 10may reject any outlier values of Z, StO₂, and PTT, and average theremaining measurements, although other methods of data analysis may beused to determine the baseline values from the collected values. Inother examples, a clinician may determine baseline values for patient 4by selecting baseline values stored in tables 70 of IMD 10 may as partof a start-up phase of treatment following the implantation of IMD 10within patient 4. In some examples, IMD 10 also may determine thresholdvalues for each of the baseline Z, StO₂, and PTT values for patient 4.For example, processing circuitry 50 may determine the threshold valuesfor patient 4 based on the determined baseline values for patient 4 byselecting the threshold values from tables 70. In other examples, aclinician may select threshold values for patient 4, which IMD then mayassociate with the baseline values of Z, StO₂, and PTT for patient 4 intables 70.

After IMD 10 has determined baseline and/or threshold values of Z, StO₂,and PTT for patient 4, such as at the conclusion of a learning phase ofIMD 10, IMD 10 may begin determining current values of Z, StO₂, and PTTfor patient 4 (112). For example, processing circuitry 50 of IMD 10 mayreceive signals from one or more of electrodes 16A-16D, light emitter38, and light detectors 40A, 40B, and determine current values of Z,StO₂, and PTT based on these signals, as described above with respect toFIGS. 1-3. Next, processing circuitry 50 of IMD 10 may compare thecurrent Z, StO₂, and PTT values of patient 4 to corresponding baselinevalues of patient 4 stored in tables 70, and determine a differencebetween each of the current values of Z, StO₂, and PTT and thecorresponding baseline values (114). In some examples, processingcircuitry 50 also may determine whether a difference between one or moreof the current values and the corresponding baseline values satisfies athreshold value.

Based on the differences between the current values and the baselinevalues determined at (114) and/or the determination of whether one ormore of the differences satisfy a threshold value, processing circuitry50 then determines a heart failure status of patient 4 (116). Asdescribed herein, determining a heart failure status may comprisedetermining a change in heart failure status of the patient, e.g.,whether a change in status is sufficient to indicate acutedecompensation.

In some examples, a threshold change value for a given parameter may bean absolute value of a percentage of the baseline value. For example, ifa baseline value of Z=X, then a threshold value of Z may be X±0.2X. Inother examples, one or more of Z, StO₂, and PTT may be associated withmultiple threshold values that correspond to different percentages ofthe baseline values, which may take into account differences insignificance between values that exceed a baseline value and values thatare less than a baseline value. For example, if a baseline value of Z=X,then threshold values of Z may be X+0.2X and X−0.1X, where values of Zthat are less than X have relatively greater significance than values ofZ that are greater than X. In any such examples, the threshold valuesmay be based on deviations from corresponding baseline values, such asstandard deviations or any other suitable statistical functions.

IMD 10 may repeat steps 112-116 to periodically determine updated heartfailure statuses of patient 4 such as daily, weekly, monthly, or at anyother suitable period. In some examples, the heart failure status ofpatient 4 may comprise a diagnostic score that indicates a likelihoodthat patient 4 may require hospitalization within a certain period oftime, based on changes in the congestion, perfusion, and vascular/bloodpressure statuses of patient 4. For example, processing circuitry 50 maydetermine a diagnostic score of patient 4 based on a combination ofvalues of one or more evidence levels associated with the current valuesof Z, StO₂, and PTT. In general, evidence levels associated with greaterseverities of congestion (as indicated by a relatively low Z),inadequate peripheral perfusion (as indicated by a relatively low StO₂),and vasoconstriction (as indicated by a relatively low PTT) may havehigher values than evidence levels associated with lesser severities ofsuch parameters of heart failure. Thus, a higher diagnostic score mayindicate that patient 4 is at a greater risk of acute decompensationand/or hospitalization or other adverse medical events within a certaintime period than a lower diagnostic score. The determination byprocessing circuitry 50 of a heart failure status of patient 4 based ondiagnostic scores is described further with respect to FIG. 8 below.Regardless of whether the heart failure status of patient 4 determinedby processing circuitry 50 comprises a diagnostic score, processingcircuitry then transmits the heart failure status of patient 4 to aremote computer, such as external device 12 (118).

FIG. 7 is a flow diagram illustrating an example technique fordetermining the baseline or current values of tissue impedance, tissueoxygen saturation, and pulse transit time described with respect to FIG.6. For example, processing circuitry 50 of IMD 10 may generate one of acurrent or voltage signal, deliver the signal via a selected two or moreof electrodes 16A-16D, and measure the resulting other of current orvoltage. Processing circuitry 50 then may determine an impedance signalbased on the delivered current or voltage and the measured voltage orcurrent. Based on the signal, processing circuitry 50 determines animpedance value of subcutaneous tissue of patient 4 in the region ofimplanted IMD 10 (120). The subcutaneous tissue impedance value may beused as current value Z of patient 4, which is a measure of a congestionstatus of patient 4 and pertains to a heart failure status of patient 4.For example, a relatively low value of Z may indicate a relatively highamount of blood and/or other fluid in the subcutaneous tissue near IMD10. Thus, if the current value of Z is relatively low and/or is lowerthan a previous measured value of Z, patient 4 may be experiencing anincrease in congestion, which may be reflected in a diagnostic scoredetermined by processing circuitry 50.

To determine a current value of PTT for patient 4, processing circuitry50 receives cardiac EGM signals (e.g., ECG signals) from at least two ofelectrodes 16A-16D, and detects a depolarization, such as a beginning ofan R wave, within the depolarization (122). In some examples, at leastone of the electrodes 16A-16D that transmit cardiac EGM signals toprocessing circuitry 50 may be an electrode used to transmit a signalindicative of a subcutaneous tissue impedance value to processingcircuitry 50, although in other examples, there may not be such overlapin electrode usage. Processing circuitry 50 determines a current StO₂value based on signals received by processing circuitry 50 from lightdetectors 40A, 40B. In order to generate such signals, processingcircuitry 50 may control light emitter 38 to emit light at one or morewavelengths in the NIR and/or visible spectra into the subcutaneoustissue adjacent IMD 10. A portion of the emitted light is absorbed bythe tissue of patient 4, and a portion of the emitted light is reflectedby the tissue and received by light detectors 40A, 40B. Light detectors40A, 40B then generate electrical signals indicating the intensities ofthe received light, which processing circuitry 50 evaluates in order todetermine a current StO₂ value of patient 4 (124). Processing circuitry50 additionally receives signals from light detectors 40A, 40B, whichmay comprise electrical signals indicative of intensities of lightdetected by light detectors 40A, 40B, and monitors the signals forfluctuations corresponding to a pulse of blood ejected during theobserved cardiac cycle passing through the portion of the vasculaturenear light detectors 40A, 40B. As discussed above with respect to FIG.2, processing circuitry 50 may determine an amount of time between thedetection of the cardiac cycle by processing circuitry 50 and the timeof associated blood passing light detectors 40A, 40B (124), and identifythe amount of time as a current PTT value of patient 4 (126). In otherexamples, such as those discussed above with respect to FIG. 2,processing circuitry 50 may determine a current PTT value of patient 4based on an ECG and fluctuations in subcutaneous tissue impedancedetected by two or more of electrodes 16A-16D, instead of based on anECG and signals from optical detectors 40A, 40B.

In some examples, the current values of one or more of Z, StO₂, and PTTmay exhibit random variability. In order to account for suchvariability, a comparison of the current diagnostic score to thebaseline diagnostic score carried out by processing circuitry 50 mayinclude curve fitting and trend analysis. For example, if processingcircuitry 50 measures values of Z, StO₂, and PTT several times daily,processing circuitry may accumulate such values over a period of time(e.g., over several days or several weeks) and fit the accumulatedvalues of each of Z, StO₂, and PTT to a corresponding trendline. Then,processing circuitry 50 may use the trendlines to project correspondingcurrent values of Z, StO₂, and PTT. In this manner, processing circuitry50 may account for random fluctuations when determining current valuesof Z, StO₂, and PTT as described above, which may enhance the accuracywith which the current values of Z, StO₂, and PTT reflect thecongestion, tissue perfusion, and blood pressure statuses of patient 4.

FIG. 8 is a flow diagram illustrating an example technique fordetermining, by processing circuitry 50 of IMD 10, a current diagnosticscore of patient 4, and determining an updated heart failure status ofpatient 4 based on a comparison of the current diagnostic score to abaseline diagnostic score. A comparison of a current diagnostic score ofpatient 4 to a baseline diagnostic score of patient 4 may provideadditional information about changes in a heart failure status ofpatient 4, and may further inform monitoring and treatment decisions andimprove clinical outcomes. In some examples, a current diagnostic scoremay be determined based on weighted values of the differences betweencurrent values (Z, StO₂, and PTT) of patient 4 and the correspondingbaseline values. For example, processing circuitry 50 may determine adifference between current values of each of Z, StO₂, and PTT and thecorresponding baseline values of patient 4, as described with respect toFIG. 6. Then, processing circuitry 50 may determine a weighted value foreach of the differences between the current values and the correspondingbaseline values. Specifically, processing circuitry 50 determines aweighted value of a difference between the current Z and the baseline Zof patient 4 (130), a weighted value of a difference between the currentStO₂ and the baseline StO₂ of patient 4 (132), and a weighted value of adifference between the current PTT and the baseline PTT of patient 4(134).

In some examples, the weights assigned by processing circuitry 50 to thedifference values may be based on factors such as a medical history ofpatient 4. As discussed above with respect to FIG. 1, processingcircuitry 50 of IMD 10 may assign such weights based on events in themedical history of patient 4, such as hospital admissions for heartfailure, medication changes, history of systolic heart failure,hypertension, respiratory illness (e.g., COPD), diabetes, atrialfibrillation, renal failure, one or more blood disorders (e.g., anemia),one or more sleep disorders (e.g., sleep apnea), among others. Forexample, patient 4 may have a medical history of becoming congested,which may indicate that patient 4 is especially likely to becomecongested in the future. Or, population-based data may indicate thatpatients having a same or similar profile of baseline values as patient4 may be particularly likely to become congested (or inadequatelyperfused or vasoconstricted). In such a situation, processing circuitry50 may assign added weight to the difference between the current Z andthe baseline Z, thereby rendering the diagnostic score of patient 4 moresensitive to fluctuations in Z values of patient 4. Similarly, weightsassigned by processing circuitry to the difference values may havenegative values, such as if a medical history of patient 4 orpopulation-based data indicate that patient 4 is unlikely to becomecongested (or inadequately perfused or vasoconstricted). Processingcircuitry 50 then may combine the weighted values of the differencesbetween the current values and the baseline values, to determine acurrent diagnostic score for patient 4 (136), and then compare thecurrent diagnostic score to a baseline diagnostic score (138). Thebaseline diagnostic score may be a diagnostic score previouslydetermined by processing circuitry 50 based on values of one or moreevidence levels associated with the baseline values of patient 4. Forexample, the baseline diagnostic score may represent a risk ofhospitalization for patient 4 when patient 4 is compensated, such aswhen a heart failure status of patient 4 is stable. Processing circuitry50 then may determine an updated heart failure status of patient 4 basedon the comparison of the baseline diagnostic score to the currentdiagnostic score (140). As in the method of FIG. 6, processing circuitry50 may transmit the updated heart failure status to a remote computer,such as external device 12. External device 12, or another remotecomputer, then may transmit instructions for a medical intervention(e.g., a change in a drug regimen, or instructions to schedule aclinician visit or seek medical attention), to an interface of a userdevice located with patient 4.

In some cases, this method of determining a heart failure status ofpatient 4 advantageously may provide context to a current diagnosticscore determined for patient 4 by taking into consideration the extentto which the current diagnostic score deviates from a baselinediagnostic score. For example, a relatively greater difference betweenthe baseline diagnostic score and the current diagnostic score mayindicate a more significant worsening of patient 4's condition than arelatively smaller difference, even with the current diagnostic scoreheld equal. In examples where a difference between the baseline andcurrent diagnostic scores is relatively great (e.g., satisfies athreshold), external device 12 may transmit instructions for moreaggressive medical interventions to a user device than examples in whichthe difference is smaller. In other examples, patient 4 may be added toa database of particularly at-risk patients, who may be monitored moreclosely by a clinician or by one or more of the devices describedherein. In any such examples, treatment may be further tailored to thespecific needs of patient 4 based on the magnitude of changes in patient4's heart failure status over time.

FIG. 9 is a flow diagram illustrating an example technique for externaldevice 12 to determine instructions for a medical intervention based ona heart failure status of patient 4 received from IMD 10, and transmitthe instructions to a user interface. The method illustrated in FIG. 9may be used with any of the methods for determining a heart failurestatus by IMD 10 described herein, such as the methods illustrated inFIGS. 6 and 8. In the illustrated example, external device 12 isconfigured to receive a heart failure status of patient 4 from IMD 10,which may be transmitted to a processing circuitry of external device 12via communication circuitry 54 and antenna 26 of IMD 10 (150).

In some examples, upon receiving the heart failure status of patient 4from IMD 10 and prior to determining instructions for a medicalintervention for patient 4, external device 12 may transmit one or morequeries to a user device. For example, external device 12 may askpatient 4 or a caregiver to answer questions about recent or currentactivities or symptoms of patient 4, such as whether patient 4 recentlyhas exercised, taken medications, or experienced symptoms. In addition,external device 12 may interrogate IMD 10 for current values of Z, StO₂,and PTT of patient 4, if IMD 10 did not already transmit the currentvalues to external device 12. Based on the heart failure status ofpatient 4, and optionally based on answers to queries and/or the currentvalues of patient 4, external device 12 then may determine instructionsfor a medical intervention for patient 4 (152).

External device 12 may determine instructions for multiple medicalinterventions for patient 4. For example, external device 12 maydetermine instructions for each of a congestion status, a peripheralperfusion status, and a vascular/blood pressure status of patient 4. Forexample, based on a congestion status of patient 4, external device 12may determine instructions for modifying (e.g., start, stop, increase,or decrease) a dose of a diuretic drug, taking another type of diureticdrug, and/or modifying a dose of a venodilator drug (e.g., nitrates).Based on a peripheral perfusion status of patient 4, external device 12may determine instructions for modifying dosages of one or more of abeta-blocker, ivabradine, or inotrope, or may recommend starting CRT orchanging CRT parameters. Based on a vascular/blood pressure status ofpatient 4, external device 12 may determine instructions for modifyingdosages of one or more of a vasoconstrictor agent (e.g., alpha-agonist)or a vasodilator agent (e.g., alpha-blocker), or may recommend seekingmedical treatment if shock is likely. In some examples, instructions formedical interventions for patient 4 may take into account the presenceof cardiac arrhythmia, as indicated by ECG signals of patient 4 detectedby IMD 10. For example, instructions determined by external device 12 inthe presence of arrhythmia may include instructions for patient 4 toavoid taking certain medications, instruct patient 4 to visit ahealthcare facility, or may recommend starting CRT or changing CRTparameters. Further, in some examples, processing circuitry of IMD 10may disregard changes in the Z, StO₂, or PTT values that occur during acardiac arrhythmia.

In some examples, external device 12 may determine the instructions formedical intervention independent of clinician input, such as byselecting among treatment options stored in a memory of external device12 or a centralized database that are associated with a diagnostic scoreand the current values of Z, StO₂, and PTT of patient 4. In otherexamples, a clinician may determine the instructions for medicalintervention on substantially the same basis, and input the instructionsto external device 12. External device 12 then may transmit theinstructions to an interface of the user device with patient 4 (154). Insome examples, external device 12 may transmit follow-up queries topatient 4 or a caregiver via the user device after transmitting theinstructions. Such queries may include questions pertaining to patient4's understanding of the transmitted instructions, whether patient 4 hascomplied with the instructed medical intervention, and/or whetherpatient 4 is experiencing symptoms. External device 12 may store patient4's responses in a memory of external device 12, or in a centralizeddatabase. A clinician may review the responses, and remotely follow-upwith patient 4 as needed following any changes to patient 4's heartfailure treatment. In this manner, the techniques and systems describedherein advantageously may enable patient 4 to receive individualized,frequently updated treatment at less expense than a comparable number ofclinician visits would incur. In addition, the techniques and systemsmay help reduce cardiac remodeling that may be caused by acutedecompensation episodes, which in turn may help minimize the progressionof a heart failure condition of patient 4.

FIGS. 10-12 are flow diagrams illustrating example techniques fordetermining appropriate medical interventions for a patient (e.g.,patient 4), depending upon qualitative assessments of three heartfailure parameters corresponding to current values of Z, StO₂, and PTTfor patient 4. The flow diagrams of FIGS. 10-12 are in the form ofdecision trees that branch off into specific hemodynamic profiles thatmay represent a heart failure status of patient 4 determined IMD 10according to the methods described above. In some examples, one or bothof external device 12 or a clinician may use the flow diagrams of FIGS.10-12, in conjunction with the heart failure status and current Z, StO₂,and PTT values of patient 4, to determine instructions for a medicalintervention for patient 4. However, for the sake of clarity, the flowdiagrams of FIGS. 10-12 are described below from the perspective ofexternal device 12, which may include processing circuitry configured tocarry out the decisions illustrated in FIGS. 10-12.

FIG. 10 is a flow diagram illustrating an example technique fordetermining appropriate medical interventions for a hypervolemic patient4 based on trends in the patient 4's tissue oxygen saturation and pulsetransit time. At the top of the flow chart of FIG. 10, external device12 has received a heart failure status of patient 4 from IMD 10 thatincludes an indication that patient 4 is hypervolemic (i.e., congested).For example, a current value of Z transmitted to external device 12 byIMD 10 may be relatively low, thereby indicating congestion. In someexamples, external device 12 may determine that patient 4 is congestedby comparing the current Z value of patient 4 to a threshold value forcongestion, and determining that the current Z value satisfies thethreshold. Such a threshold value for Z, as well as correspondingthreshold values for StO₂ and PTT described with respect to FIGS. 10-12,may be stored in a memory of external device 12 or in a centralizeddatabase.

After determining that patient 4 is congested, external device 12 maydetermine a peripheral perfusion status of patient 4 based on a currentStO₂ value of patient 4 transmitted to external device 12 by IMD 10. Forexample, external device 12 may compare the current StO₂ value ofpatient 4 to an StO₂ threshold value indicative of adequate peripheralperfusion, and determine whether the current StO₂ value is less than,approximately equal to, or greater than the threshold StO₂ value.External device 12 also may determine a vascular/blood pressure statusof patient 4 by comparing a current PTT value of patient 4 transmittedto external device 12, by comparing the current PTT value of patient 4to a PTT threshold value. The PTT threshold value may be indicative of aneutral vascular state. Thus, a current value of PTT that is greaterthan the PTT threshold value may indicate vasodilation, a current PTTvalue that is approximately equal to the PTT threshold value mayindicate neither vasodilation nor vasoconstriction, and a current PTTvalue that is less than the PTT threshold may indicate vasoconstriction.

By following the decision tree illustrated in FIG. 10 and comparing thecurrent values of StO₂ and PTT to the corresponding threshold values,external device 12 may determine a hemodynamic profile of patient 4 thatincludes congestion, peripheral perfusion, and vascular/blood pressurestatuses. However, it should be noted such statuses of patient 4 may notnecessarily reflect absolute values of congestion, tissue perfusion, orblood pressure of patient 4. For example, a blood pressure status ofpatient 4 may not necessarily be a measurement of an absolute bloodpressure value of patient 4, but instead may indicate a change in bloodpressure of patient 4 that may be associated with a change in afterload.In the example of FIG. 10, in which example external device 12 initiallyhas determined that patient 4 is congested, the possible hemodynamicprofiles of patient 4 are shown in the lower-most boxes of the flowchart of FIG. 10. For example, as shown in the lower-most box of theleft-most branch of FIG. 10, patient 4 has a hemodynamic profile thatindicates that patient 4 is congested (“volume overload”), hasinadequate peripheral perfusion (“depressed CO [cardiac output]”), andis exhibiting vasodilation (“compensatory vasodilation”).

External device 12 then may use this hemodynamic profile of patient 4 todetermine one or more medical interventions configured to reduce alikelihood that patient 4 may acutely decompensate, requirehospitalization, or experience other types of adverse medical events.For example, based on the congested status of patient 4, external device12 may instruct patient 4 to undertake medical interventions configuredto decrease excess fluid retention. Based on the inadequate perfusion ofpatient 4 in this example, external device 12 may instruct patient 4 toundertake medical interventions configured to increase heart rate (ifheart rate is too low), and/or increase contractility (if contractilityis too low). Based on the vasodilation of patient 4 in this example,external device 12 may instruct patient 4 to undertake medicalinterventions configured to cause vasoconstriction and raise bloodpressure. Regardless of the hemodynamic profile of patient 4 (i.e., thenine lower-most boxes of FIG. 10), external device 12 may determine oneor more medical interventions for patient 4 based on considerationssimilar to those described above.

In some examples, some of the medical interventions that external device12 may recommend based on one status of patient 4 may be conditioned onanother status of patient 4. For example, some medical interventions forinadequate peripheral perfusion may be conditioned upon a vascular/bloodpressure status of patient 4. Thus, in determining which medicalinterventions to instruct patient 4 to undertake, external device 12 maytake into account all three statuses of patient 4 reflected by thehemodynamic profile. In this manner, the methods and systems describedherein may provide robust heart failure treatment that takes intoaccount multiple parameters of a heart failure condition of patient 4.

FIG. 11 is a flow diagram illustrating an example technique fordetermining appropriate medical interventions for a hypovolemic patient4 based on trends in the patient 4's tissue oxygen saturation and pulsetransit time. The decision tree in FIG. 11 is substantially similar infunction to the decision tree in FIG. 10. For example, the decision treein FIG. 11 also provides a method for external device 12 to determine ahemodynamic profile of patient 4 based on the congestion, peripheralperfusion, and vascular/blood pressure statuses of patient 4, and usethe hemodynamic profile in determining which medical interventions torecommend for patient 4. Unlike the flow diagram of FIG. 10, the flowdiagram of FIG. 11 begins with a determination (e.g., by external device12) that patient 4 is hypovolemic (e.g., dehydrated). However, as withthe decision tree of FIG. 10, external device 12 may take into accountall three statuses of patient 4 reflected by a hemodynamic profile ofFIG. 11 in determining which medical interventions to instruct patient 4to undertake.

FIG. 12 is a flow diagram illustrating an example technique fordetermining appropriate medical interventions for an optivolemic patient4 based on trends in the patient 4's tissue oxygen saturation and pulsetransit time. The decision tree in FIG. 12 is substantially similar infunction to the decision trees in FIGS. 10 and 11. For example, thedecision tree in FIG. 12 also provides a method for external device 12to determine a hemodynamic profile of patient 4 based on the congestion,peripheral perfusion, and vascular/blood pressure statuses of patient 4,and use the hemodynamic profile in determining which medicalinterventions to recommend for patient 4. Unlike the flow diagram ofFIGS. 10 and 11, the flow diagram of FIG. 12 begins with a determination(e.g., by external device 12) that patient 4 is optivolemic (e.g.,neither congested nor dehydrated). However, as with the decision treesof FIGS. 10 and 11, external device 12 may take into account all threestatuses of patient 4 reflected by a hemodynamic profile of FIG. 12 indetermining which medical interventions to instruct patient 4 toundertake.

Although processing circuitry 50 of IMD 10 and processing circuitry ofexternal device 12 is described above as being configured to perform oneor more of the steps of the techniques illustrated in FIGS. 6-12, anysteps of the techniques described herein may be performed by processingcircuitry of the other of IMD 10 or external device 12, or by one ormore other devices. For example, processing circuitry of external device12, or of any other suitable implantable or external device or server,may be configured to perform one or more of the steps described as beingperformed by processing circuitry 50 of IMD 10. In other examples,processing circuitry 50 of IMD 10, or of any other suitable implantableor external device or server, may be configured to perform one or moreof the steps described as being performed by processing circuitry ofexternal device 12. Such other implantable or external devices mayinclude, for example, an implantable pacemaker or ICD, an externalmonitoring device, or any other suitable device. In addition, althoughthe optical sensors and electrodes are described herein as beingpositioned on a housing of IMD 10, in other examples, such opticalsensors and/or electrodes may be positioned on a housing of anotherdevice implanted in or external to patient 4, such as a transvenous,subcutaneous, or extravascular pacemaker or ICD, or coupled to such adevice by one or more leads.

In some examples, the techniques described herein (e.g., with respect toFIGS. 6-12) may include determining values of one or more otherparameters in addition to or instead of any of Z, StO₂, and PTT. Asdescribed above with respect to FIG. 1, sensors on IMD 10 or one or moreother implanted or external devices may be configured to sense signalsassociated with such parameters. For example, one or more implanted orexternal devices of medical system 2 (e.g., IMD 10) may include one ormore sensors configured to sense blood or tissue levels of one or morecompounds associated with kidney function of patient 4, such ascreatinine or blood urea nitrogen. In such examples, techniques fordetermining a heart failure status of patient 4 may include determining,by processing circuitry of IMD 10, external device 12, or one or moreother implanted or external devices or servers, a current value of theone or more other parameters, comparing such a current value to acorresponding baseline, and using the comparison in determining theheart failure status of patient 4. In some examples, such one or moreother parameters may not be directly associated with changes in a heartfailure status, but may provide other information about the health ofpatient 4, such as activity levels or sleep patterns. In any suchexamples, external device 12, or another suitable device, may determinethe instructions for medical intervention for patient 4 at leastpartially based on a status of patient 4 associated with the one or moreother parameters, such as a kidney status of patient 4 associated with acurrent creatinine value of patient 4.

Various aspects of the techniques may be implemented within one or moreprocessors, including one or more microprocessors, DSPs, ASICs, FPGAs,or any other equivalent integrated or discrete logic circuitry, as wellas any combinations of such components, embodied in programmers, such asphysician or patient programmers, electrical stimulators, or otherdevices. The term “processor” or “processing circuitry” may generallyrefer to any of the foregoing logic circuitry, alone or in combinationwith other logic circuitry or any other equivalent circuitry.

In one or more examples, the functions described in this disclosure maybe implemented in hardware, software, firmware, or any combinationthereof. If implemented in software, the functions may be stored on, asone or more instructions or code, a computer-readable medium andexecuted by a hardware-based processing unit. Computer-readable mediamay include computer-readable storage media forming a tangible,non-transitory medium. Instructions may be executed by one or moreprocessors, such as one or more DSPs, ASICs, FPGAs, general purposemicroprocessors, or other equivalent integrated or discrete logiccircuitry. Accordingly, the terms “processor” or “processing circuitry”as used herein may refer to one or more of any of the foregoingstructures or any other structure suitable for implementation of thetechniques described herein.

In addition, in some aspects, the functionality described herein may beprovided within dedicated hardware and/or software modules. Depiction ofdifferent features as modules or units is intended to highlightdifferent functional aspects and does not necessarily imply that suchmodules or units must be realized by separate hardware or softwarecomponents. Rather, functionality associated with one or more modules orunits may be performed by separate hardware or software components, orintegrated within common or separate hardware or software components.Also, the techniques could be fully implemented in one or more circuitsor logic elements. The techniques of this disclosure may be implementedin a wide variety of devices or apparatuses, including an IMD, anexternal programmer, a combination of an IMD and external programmer, anintegrated circuit (IC) or a set of ICs, and/or discrete electricalcircuitry, residing in an IMD and/or external programmer.

Various aspects of the disclosure have been described. These and otheraspects are within the scope of the following claims.

What is claimed is:
 1. A method for determining a heart failure statusof a patient using an implantable medical device configured forsubcutaneous implantation outside of a thorax of the patient, theimplantable medical device comprising a plurality of electrodes and atleast one optical sensor, the method comprising, by processing circuitryof a medical device system comprising the implantable medical device:determining a current tissue oxygen saturation value of the patientbased on a signal received from the at least one optical sensor;determining a current tissue impedance value of the patient based on asubcutaneous tissue impedance signal received from a first at least twoof the plurality of electrodes; determining a current pulse transit timevalue of the patient based on a cardiac electrogram signal received froma second at least two of the plurality of electrodes and at least one ofthe signal received from the at least one optical sensor and thesubcutaneous tissue impedance signal; comparing the current tissueoxygen saturation value, the current tissue impedance value, and thecurrent pulse transit time value to corresponding ones of a baselinetissue oxygenation saturation value, a baseline tissue impedance value,and a baseline pulse transit time value; and determining the heartfailure status of the patient based on the comparison.
 2. The method ofclaim 1, wherein comparing the current tissue oxygen saturation value,the current tissue impedance value, and the current pulse transit timevalue to the corresponding ones of the baseline tissue oxygenationsaturation value, the baseline tissue impedance value, and the baselinepulse transit time value comprises: determining whether a differencebetween the current tissue oxygen saturation value and the baselinetissue oxygen saturation value satisfies a tissue oxygen saturationthreshold value that is associated with a change in a tissue perfusionstatus of the patient; determining whether a difference between thecurrent tissue impedance value and the baseline tissue impedance valuesatisfies a tissue impedance threshold value that is associated with achange in a congestion status of the patient; and determining whether adifference between the current pulse transit time value and the baselinepulse transit time value satisfies a threshold pulse transit time valuethat is associated with a change in a blood pressure status of thepatient.
 3. The method of claim 1, further comprising, by the processingcircuitry: transmitting the heart failure status of the patient to aremote computer; receiving, from the remote computer, instructions for amedical intervention based on the heart failure status of the patient;and transmitting the instructions for the medical intervention to a userinterface.
 4. The method of claim 3, wherein the instructions for themedical intervention comprise at least one of a change in a drugselection, a change in a drug dosage, instructions to schedule a visitwith a clinician, and instructions for the patient to seek medicalattention.
 5. The method of claim 1, wherein determining the heartfailure status of the patient based on the comparison comprisesdetermining, by the processing circuitry, a diagnostic score based onthe comparison, wherein the diagnostic score is associated with alikelihood that the patient will experience an adverse medical event. 6.The method of claim 5, wherein the heart failure status of the patientis an updated heart failure status, and wherein determining the updatedheart failure status comprises comparing, by the processing circuitry, acurrent diagnostic score to a baseline diagnostic score of the patient.7. The method of claim 6, further comprising, by the processingcircuitry, determining the current diagnostic score by at least:determining a weighted value of the difference between the currenttissue oxygen saturation value and the baseline tissue oxygen saturationvalue; determining a weighted value of the difference between thecurrent tissue impedance value and the baseline tissue impedance value;determining a weighted value of the difference between the current pulsetransit time value and the baseline pulse transit time value; andcombining the weighted value of the difference between the currenttissue oxygen saturation value and the baseline tissue oxygen saturationvalue, the weighted value of the difference between the current tissueimpedance value and the baseline tissue impedance value, and theweighted value of the difference between the current pulse transit timevalue and the baseline pulse transit time value.
 8. The method of claim1, wherein the signals are current signals, the method furthercomprising: receiving a baseline signal from the at least one opticalsensor; receiving a baseline subcutaneous tissue impedance signal fromthe first at least two of the plurality of electrodes; receiving abaseline cardiac electrogram signal from the second at least two of theplurality of electrodes; determining at least one of the baseline tissueoxygen saturation value or the tissue oxygen saturation threshold valuebased on the baseline signal received from the at least one opticalsensor; determining at least one of the baseline tissue impedance valueor the tissue impedance threshold value based on the baselinesubcutaneous tissue impedance signal from the first at least two of theplurality of electrodes; and determining at least one of the baselinepulse transit time value or the threshold pulse transit time value basedon the baseline cardiac electrogram signal and at least one of thebaseline signal received from the at least one optical sensor or thebaseline subcutaneous tissue impedance signal.
 9. The method of claim 1,wherein the first at least two of the plurality of electrodes and thesecond at least two of the plurality of electrodes include at least oneelectrode of the plurality of electrodes in common.
 10. The method ofclaim 1, wherein the implantable medical device comprises a housingconfigured for subcutaneous implantation outside the thorax, and whereinthe at least one optical sensor and the plurality of electrodes arepositioned on the housing.
 11. The method of claim 1, wherein theimplantable medical device comprises a leadless implantable medicaldevice.
 12. A system for determining a heart failure status of a patientusing an implantable medical device configured for subcutaneousimplantation outside of a thorax of the patient, the system comprising:the implantable medical device comprising: at least one optical sensor;and a plurality of electrodes; and processing circuitry configured to:determine a current tissue oxygen saturation value of the patient basedon a signal received from the at least one optical sensor; determine acurrent tissue impedance value of the patient based on a subcutaneoustissue impedance signal received from a first at least two of theplurality of electrodes; determine a current pulse transit time value ofthe patient based on a cardiac electrogram signal received from a secondat least two of the plurality of electrodes and at least one of thesignal received from the at least one optical sensor and thesubcutaneous tissue impedance signal; compare the current tissue oxygensaturation value, the current tissue impedance value, and the currentpulse transit time value to corresponding ones of a baseline tissueoxygenation saturation value, a baseline tissue impedance value, and abaseline pulse transit time value; and determine the heart failurestatus of the patient based on the comparison.
 13. The system of claim12, wherein the processing circuitry is configured to compare thecurrent tissue oxygen saturation value, the current tissue impedancevalue, and the current pulse transit time value to the correspondingones of the baseline tissue oxygenation saturation value, the baselinetissue impedance value, and the baseline pulse transit time value by atleast: determining whether a difference between the current tissueoxygen saturation value and the baseline tissue oxygen saturation valuesatisfies a tissue oxygen saturation threshold value that is associatedwith a change in a tissue perfusion status of the patient; determiningwhether a difference between the current tissue impedance value and thebaseline tissue impedance value satisfies a tissue impedance thresholdvalue that is associated with a change in a congestion status of thepatient; and determining whether a difference between the current pulsetransit time value and the baseline pulse transit time value satisfies athreshold pulse transit time value that is associated with a change in ablood pressure status of the patient.
 14. The system of claim 12,wherein the processing circuitry is further configured to: transmit theheart failure status of the patient to a remote computer; receive, fromthe remote computer, instructions for a medical intervention based onthe heart failure status of the patient; and transmit the instructionsfor the medical intervention to a user interface.
 15. The system ofclaim 14, wherein the instructions for the medical intervention compriseat least one of a change in a drug selection, a change in a drug dosage,instructions to schedule a visit with a clinician, and instructions forthe patient to seek medical attention.
 16. The system of claim 12,wherein the processing circuitry is configured to determine the heartfailure status of the patient based on the comparison by at leastdetermining a diagnostic score based on the comparison, wherein thediagnostic score is associated with a likelihood that the patient willexperience an adverse medical event.
 17. The system of claim 16, whereinthe heart failure status of the patient is an updated heart failurestatus, and wherein the processing circuitry is configured to determinethe updated heart failure status by at least comparing a currentdiagnostic score to a baseline diagnostic score of the patient.
 18. Thesystem of claim 17, wherein the processing circuitry is furtherconfigured to determine the current diagnostic score by at least:determining a weighted value of the difference between the currenttissue oxygen saturation value and the baseline tissue oxygen saturationvalue; determining a weighted value of the difference between thecurrent tissue impedance value and the baseline tissue impedance value;determining a weighted value of the difference between the current pulsetransit time value and the baseline pulse transit time value; andcombining the weighted value of the difference between the currenttissue oxygen saturation value and the baseline tissue oxygen saturationvalue, the weighted value of the difference between the current tissueimpedance value and the baseline tissue impedance value, and theweighted value of the difference between the current pulse transit timevalue and the baseline pulse transit time value.
 19. The system of claim12, wherein the signals are current signals, and wherein the processingcircuitry is further configured to: receive a baseline signal from theat least one optical sensor, receive a baseline subcutaneous tissueimpedance signal from the first at least two of the plurality ofelectrodes, receive a baseline cardiac electrogram signal from thesecond at least two of the plurality of electrodes, determine at leastone of the baseline tissue oxygen saturation value or the tissue oxygensaturation threshold value based on the baseline signal received fromthe at least one optical sensor, determine at least one of the baselinetissue impedance value or the tissue impedance threshold value based onthe baseline subcutaneous tissue impedance signal from the first atleast two of the plurality of electrodes, and determine at least one ofthe baseline pulse transit time value or the threshold pulse transittime value based on the baseline cardiac electrogram signal and at leastone of the baseline signal received from the at least one optical sensoror the baseline subcutaneous tissue impedance signal.
 20. The system ofclaim 12, wherein the first at least two of the plurality of electrodesand the second at least two of the plurality of electrodes include atleast one electrode of the plurality of electrodes in common.
 21. Thesystem of claim 12, wherein the implantable medical device comprises ahousing configured for subcutaneous implantation outside the thorax, andwherein the at least one optical sensor and the plurality of electrodesare positioned on the housing.
 22. The system of claim 12, wherein theimplantable medical device comprises a leadless implantable medicaldevice.
 23. A system for determining a heart failure status of a patientusing an implantable medical device configured for subcutaneousimplantation outside of a thorax of the patient, the system comprising:the implantable medical device, comprising: at least one optical sensor;a plurality of electrodes; and processing circuitry configured to:determine a current tissue oxygen saturation value of the patient basedon the signal received from the at least one optical sensor; determine acurrent tissue impedance value of the patient based on a subcutaneoustissue impedance signal received from a first at least two of theplurality of electrodes; determine a current pulse transit time value ofthe patient based on a cardiac electrogram signal received from a secondat least two of the plurality of electrodes and at least one of thesignal received from the at least one optical sensor and thesubcutaneous tissue impedance signal; determine whether a differencebetween the current tissue oxygen saturation value and the baselinetissue oxygen saturation value satisfies a tissue oxygen saturationthreshold value that is associated with a change in a tissue-perfusionstatus of the patient; determine whether a difference between thecurrent tissue impedance value and the baseline tissue impedance valuesatisfies a tissue impedance threshold value that is associated with achange in a congestion status of the patient; determine whether adifference between the current pulse transit time value and the baselinepulse transit time value satisfies a threshold pulse transit time valuethat is associated with a change in a blood-pressure status of thepatient; determine the heart failure status of the patient based on atleast one of the difference between the current tissue oxygen saturationvalue and the baseline tissue oxygen saturation value, the differencebetween the current tissue impedance value and the baseline tissueimpedance value, and the difference between the current pulse transittime and the baseline pulse transit time; and transmit the heart failurestatus of the patient to a remote computer; and the remote computer,wherein the remote computer comprises processing circuitry configuredto: receive the heart failure status of the patient transmitted by theprocessing circuitry of the implantable medical device; and transmit theinstructions for the medical intervention to a user interface.
 24. Asystem for determining a heart failure status of a patient, the systemcomprising: means for determining a current tissue oxygen saturationvalue of the patient based on a signal received from at least oneoptical sensor; means for determining a current tissue impedance valueof the patient based on a subcutaneous tissue impedance signal receivedfrom a first at least two of a plurality of electrodes; means fordetermining a current pulse transit time value of the patient based on acardiac electrogram signal received from a second at least two of theplurality of electrodes and at least one of the signal received from theat least one optical sensor and the subcutaneous tissue impedancesignal; means for comparing the current tissue oxygen saturation value,the current tissue impedance value, and the current pulse transit timevalue to corresponding ones of a baseline tissue oxygenation saturationvalue, a baseline tissue impedance value, and a baseline pulse transittime value; and means for determining the heart failure status of thepatient based on the comparison.
 25. The system of claim 24, wherein themeans for comparing the current tissue oxygen saturation value, thecurrent tissue impedance value, and the current pulse transit time valueto the corresponding ones of the baseline tissue oxygenation saturationvalue, the baseline tissue impedance value, and the baseline pulsetransit time value comprises: means for determining whether a differencebetween the current tissue oxygen saturation value and the baselinetissue oxygen saturation value satisfies a tissue oxygen saturationthreshold value that is associated with a change in a tissue perfusionstatus of the patient; means for determining whether a differencebetween the current tissue impedance value and the baseline tissueimpedance value satisfies a tissue impedance threshold value that isassociated with a change in a congestion status of the patient; andmeans for determining whether a difference between the current pulsetransit time value and the baseline pulse transit time value satisfies athreshold pulse transit time value that is associated with a change in ablood pressure status of the patient.
 26. A non-transitorycomputer-readable medium storing instructions for causing processingcircuitry to perform a method for determining a heart failure status ofa patient using an implantable medical device configured forsubcutaneous implantation outside of a thorax of the patient, theimplantable medical device comprising a plurality of electrodes and atleast one optical sensor, the method comprising: determining a currenttissue oxygen saturation value of the patient based on a signal receivedfrom the at least one optical sensor; determining a current tissueimpedance value of the patient based on a subcutaneous tissue impedancesignal received from a first at least two of the plurality ofelectrodes; determining a current pulse transit time value of thepatient based on a cardiac electrogram signal received from a second atleast two of the plurality of electrodes and at least one of the signalreceived from the at least one optical sensor and the subcutaneoustissue impedance signal; comparing the current tissue oxygen saturationvalue, the current tissue impedance value, and the current pulse transittime value to corresponding ones of a baseline tissue oxygenationsaturation value, a baseline tissue impedance value, and a baselinepulse transit time value; and determining the heart failure status ofthe patient based on the comparison.
 27. The non-transitorycomputer-readable medium of claim 26, wherein the method furthercomprises: determining whether a difference between the current tissueoxygen saturation value and the baseline tissue oxygen saturation valuesatisfies a tissue oxygen saturation threshold value that is associatedwith a change in a tissue perfusion status of the patient; determiningwhether a difference between the current tissue impedance value and thebaseline tissue impedance value satisfies a tissue impedance thresholdvalue that is associated with a change in a congestion status of thepatient; and determining whether a difference between the current pulsetransit time value and the baseline pulse transit time value satisfies athreshold pulse transit time value that is associated with a change in ablood pressure status of the patient.
 28. A system for determining aheart failure status of a patient, the system comprising: one or moresensors configured to monitor one or more parameters of the patient; andprocessing circuitry configured to: determine current values of the oneor more parameters of the patient based on one or more signals receivedfrom the one or more sensors, the one or more parameters comprising asurrogate parameter for congestion, a surrogate parameter for tissueperfusion, and a surrogate parameter for blood pressure; compare thecurrent value of the surrogate parameter for congestion, the currentvalue of the surrogate parameter for tissue perfusion, and the currentvalue of the surrogate parameter for blood pressure to correspondingones of a baseline value of the surrogate parameter for congestion, abaseline value of the surrogate parameter for tissue perfusion, and abaseline value of the surrogate parameter for blood pressure; anddetermine the heart failure status of the patient based on thecomparison.